Columbia  ®nitjergitp  ,^c;  rf 
mtt)eCitj>ofi^eto|9orfe 

^ci)ool  of  Bental  anb  0val  ^urgerp 


J^eference  Hibrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/principlesofsurgOOtill 


A    TEXT -BOOK    OF 
SUEOEEY 


BY 

Dr.   HERMANN   TILLMANNS 

PROFESSOR   IN  THE   UNIVERSITY   OF  LEIPSIC 


TRANSLATED  FROM  THE   THIRD  0ER3IAN  EDITION  BY 

JOHN   ROGERS,   M.  D.,   New  York,  and 
BENJAMIN   T.   TILTON,   M.  D.,   New  York 


Edited   by    LEWIS    A.    STIMSON,   M.  D. 

PROFESSOR  OF  SURGERY   IN   THE   NEW  YORK   UNIVERSITY 


VOLUME  I 

THE   PRINCIPLES  OF   SURGERY 
AND   SURGICAL  PATHOLOGY 

GENERAL  RULES  GOVERNING  OPERATIONS 
AND  THE  APPLICATION  OF  DRESSINGS 

WITH  FOUR   HUNDRED   AND   FORTY- ONE   ILLUSTRATIONS 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1898 


&         t 


*n 


Copyright,  1894,  1897, 
By  D.  APPLETON  AND  COMPANY. 


Electrottped  and  Printed 
AT  THE  Appleton  Press,  U.  S.  A. 


PREFACE. 


The  great  advances  that  have  been  made  in  recent  years  in  our 
knowledge  of  the  minute  processes  and  tissue  changes  in  disease,  of  the 
causes  tliat  underlie  them,  and  of  the  principles  of  repair,  have  estab- 
lished the  practice  of  surgery  upon  a  much  broader  and  more  scientific 
foundation  than  it  formcrl_y  had  ;  and  the  surgeon  of  to-day  who  wishes 
his  work  to  be  thorough,  intelligent,  and  fruitful  of  good  results  must 
make  this  knowledge  all  his  own  and  must  build  upon  this  foundation. 
Nowhere  is  this  need  more  keenly  appreciated  than  in  our  medical 
schools,  where  it  has  long  been  recognised  that  the  student  must  gain 
a  thorough  knowledge  of  surgical  pathology  before  he  can  listen  with 
advantage  to  didactic  and  clinical  lectures  upon  special  forms  of  sur- 
gical disease  and  injury. 

The  makers  of  even  the  most  recent  surgical  text-books  in  the  English 
language  have  adhered,  in  the  main,  to  the  old  division  and  arrange- 
ment of  their  subjects,  and  instead  of  adding  to  the  general  group  of 
inflammations,  surgical  complications,  and  general  surgical  diseases, 
the  kindred  subjects  of  the  general  surgical  injuries  and  diseases  of  the 
various  tissues,  they  have  separated  the  latter  and  combined  them  with 
the  study  of  their  numerous  and  varied  local  forms  in  regional  surgery. 
Moreover,  the  general  need  of  keeping  the  work  within  relatively  nar- 
row limits  has  led  to  a  correspondingly  concise  and  restricted  presen- 
tation of  the  general  pathology  of  each  subject,  one  unsuited  to  the 
needs  of  both  the  beginner  and  the  practitioner  who  is  in  search  of 
detailed  information. 

On  the  other  hand,  the  Germans,  and  to  some  extent  the  French, 
have  divided  their  text-books  into  two  distinct  parts,  the  "general" 
and  the  "  special  "  ;  including  in  the  former  not  only  the  general  affec- 
tions and  pathology,  but  also  the  pathology  and  principles  of  treatment 
of  the  injuries  and  diseases  of  the  various  tissues,  and  confining  the 
latter  to  the  consideration  of  their  local  manifestations  in  regional 
surgery ;  and  the  space  given  to  general  surgery  in  their  best-known 
text-books  is  nearly  or  quite  equal  to  that  given  to  both  subjects  in  ours. 

(iii^ 


iv  PREFACE. 

A  consideration  of  these  facts  and  of  the  special  needs  of  their 
students  led  some  of  the  professors  of  surgery  in  New  York  to  suggest 
the  present  translation,  and  as  the  project  met  with  the  approval  of 
others  similarly  concerned  with  medical  education  it  was  undertaken. 

Tillmanns'  Surgery  was  selected  as  the  one  best  suited  for  the  pur- 
pose, and  it  is  hoped  that  it  will  receive  in  its  present  form  the  favour 
It  has  so  widely  enjoyed  in  the  original. 

John  Rogers,  M.  D. 

14  West  Twelfth  Street. 


CONTENTS. 


FIRST  SECTION. 
GENERAL  PRINCIPLES  GOVERNING  SURGICAL  OPERATIONS. 

I.  The  Preparations  for  an  Aseptic  Operation. 

SECTION  PAGE 

4.  Deftiiition  of  a  surgical  operation 1 

5.  Indications  and  counter-indications  for  undertaking  an  operation   ...  2 

6.  The  preparations  for  an  aseptic  operation.   Antisepsis  and  asepsis-  ...  2 

II.  The  Alleviation  of  Pain  during  Operations. — Narcosis. — Local 

Anesthesia. 

7.  The  alleviation  of  pain  during  the  operation 14 

8.  Chloroform  narcosis 16 

9.  Technique  of  chloroform  narcosis        ,        .        • 18 

10.  Symptomatology  of  chloroform  narcosis 23 

11.  Accidents  occurring  during  chloroform  narcosis 25 

12.  The  occurrence  and  cause  of  death  during  narcosis 27 

13.  Treatment  of  common  accidents  occurring  during  chloroform  narcosis    ,        .  33 

14.  Ether  narcosis 37 

15.  Laughing-gas  narcosis 39 

16.  Mixed  narcosis  and  other  anaesthetics 40 

1 7.  Local  anjesthesia . 43 

III.  The  Prevention  op  Loss  of  Blood  during  an  Operation. 

18.  The  prevention  of  loss  of  blood  during  an  operation 47 

19.  Esmarch's  artificial  ischaeraia 48 

IV.  General  Rules  for  performing  an  Aseptic  Operation  and  for 
the  After-treatment  of  the  Patient. 

20.  Performance  of  an  aseptic  operation  .        .  ■ 55 

21.  The  accidents  during  an  operation 56 

22.  The  post-operative  treatment  of  patients 61 

23.  The  most  important  causes  of  death  after  operation 62 

V.  The  Different  Ways  of  dividing  the  Tissues. 

24.  The  division  of  the  soft  parts  (accompanied  by  the  loss  of  blood)     ...  64 

25.  Bloodless  division  of  the  tissues  without  cutting,  by  tearing,  twisting,  etc.      .  72 

26.  The  division  of  bone 80 


yi  CONTENTS. 

VI.  The  Methods  of  arresting  Hemorrhage. 

PAGE 

27.  The  arrest  of  hjemon-hage  during  operations 86 

28.  Substitutes  for  the  ligation  of  vessels 90 

29.  Other  metliods  of  ha-mostasis 92 

30.  Ligation  of  arteries  in  continuity 95 

VII.  Drainage  of  Wounds. 

31.  The  method  of  allowing  the  secretions  of  a  wound  to  escape     ....  98 

VIII.  The  Method  of  uniting  the  Tissues.— Suture  of  the  Wound. 

32.  Disinfection  of  the  wound  before  inserting  the  sutures 103 

33.  The  method  of  uniting  the  soft  parts— Suture  of  the  wound    ....  104 

34.  The  method  of  uniting  wound  surfaces  of  bone 110 

IX.  Amputations,  Disarticulations,  and  Resections. — General  Considerations. 

35.  General  considerations  in  performing  amputations  and  disarticulations  .        .  -112 

36.  General  considerations  in  regard  to  amputations 114 

37.  The  method  of  performing  disarticulations 123 

38.  The  after-treatment  of  amputations  and  disarticulations 124 

39.  Artificial  limbs 127 

40.  Operations  on  joints 138 

X.  Operations  for  Remedying  Defects  in  the  Tissues. — Plastic 
Operations. — Transplantation. 

41.  Plastic  operations  for  cutaneous  defects 135 

42.  Skin-grafting  according  to  Reverdin  and  Thiersch 141 

43.  Plastic  operations  on  other  tissues 144 


SECOND   SECTION. 
THE  METHODS  OF  APPLYING  SURGICAL  DRESSINGS. 

I.  The  Antiseptic  and  Aseptic  Protective  Dressings. 

44.  General  principles  governing  antiseptic  or  aseptic  dressings     . 

45.  The  most  common  antiseptic  and  aseptic  dressings 

46.  The  different  antiseptics 

47.  Which  antiseptics  and  which  antiseptic  or  aseptic  dressings  are  the  best? 

48.  The  changing  of  an  antiseptic  or  an  aseptic  dressing         .... 

II.  Other  Methods  of  treating  Wounds. 

49.  Other  dressings  for  wounds 177 

III.  General  Rules  for  the  Application  of  Bandages  and  Retention 

Appliances. 

50.  Application  of  bandages      . 185 

51.  Application  of  suitably  shaped  pieces  of  cloth  in  place  of  bandages         .        .    194 

IV.  The  Sick-bed  op  the  Patient.— Immobilisation  Appliances  and  Dressings. 

52.  The  sick-bed  of  the  patient 200 

53.  Sick-bed  appliances— Splints,  cushions,  etc 202 


146 

148 
152 
170 
173 


CONTENTS.  vii 

V.  The  Application  ok  Tmmorilisino  Dressings  made  of  Materials  which 

GRADUALLY    HARDEN. 

I'AliE 

54.  Immobilisation  dressings  of  hardening  substances 216 

55.  The  method  of  applying  extension  by  a  weight 224 


THIRD  SECTION. 
SURGICAL  PATHOLOGY  AND   THERAPY. 

I.  Inflammation  and  Injuries. 

56.  Inflammation 232 

57.  Causes  of  iiiflainination 239 

58.  Symptoms,  diagnosis,  and  treatment  of  inflammation 241 

59.  Morphology  and  general  significance  of  micro-organisms 252 

60.  General  remarks  concerning  injuries 277 

61.  The  anatomical  phenomena  in  the  healing  of  a  wound 280 

62.  The  general  reaction  which  follows  an  injury  and  an  inflammation.— Fever   .  300 

63.  Shock 313 

64.  Delirium  tremens 316 

65.  Delirium  nervosum  and  psychical  disturbances  which  may  follow  injuries  and 

operations 317 

66.  The  infectious-wound  diseases 318 

67.  Inflammation  and  suppuration  of  a  wound — Etiology 320 

68.  Lymphangitis,  lymphadenitis 326 

69.  Arteritis  and  phlebitis 329 

70.  Cellulitis 831 

71.  Erysipelas 339 

72.  flospital  gangrene — Wound  diphtheria 351 

73.  Traumatic  tetanus 354 

74.  SepticiBmia 363 

75.  Pyaemia 373 

76.  Infection  by  cadaveric  poisoning 379 

77.  Splenic  fever,  or  anthrax 381 

78.  Glanders,  or  farcy 390 

79.  Foot-and-mouth  disease 394 

80.  Hydrophobia 395 

81.  Poisoning  by  insects,  snakes,  etc 403 

82.  The  poisoning  of  wounds  by  Indian  arrow  poison 405 

Appendix.     Chronic  Mycoses :  Tuberculosis  (Scrofula),  Syphilis,  Leprosy, 

Actinomycosis. 

83.  Tuberculosis 406 

84.  Syphilis 425 

85.  Leprosy 437 

86.  Actinomycosis 441 

II.  Injuries  and  Surgical  Diseases  op  the  Soft  Parts. 

87.  Wounds  of  soft  parts 448 

88.  The  treatment  of  wounds  of  soft  parts 464 

89.  Treatment  of  the  conditions  following  severe  haemorrhages — Blood  and  com- 

mon salt  infusion         .       , 478 


viii  CONTENTS. 

90.  Burns 

91.  Effects  of  cold  (freezing)    .... 

92.  Subcutaneous  injuries  of  soft  parts  . 

93.  The  diseases  of  the  skin  and  cellular  tissue 

94.  The  diseases  of  the  mucous  membranes    . 

95.  Inflammations  and  diseases  of  blood-vessels 

96.  The  diseases  of  the  lymphatic  system 

97.  The  diseases  of  the  peripheral  nerves 

98.  The  diseases  of  muscles,  tendons,  and  tendon- 

99.  The  diseases  of  the  bursae  .... 
100.  Gangrene  (necrosis)  of  the  soft  parts 


heath 


PACK 

484 
494 
497 
510 
525 
530 
543 
545 
549 
558 
561 


III.  Injuries  and  Surgical  Diseases  of  Bone. 

101.  Fractures 567 

102.  Contusions  and  wounds  of  bone 607 

103.  The  inflammations  of  bone 609 

104.  Acute  inflammations  of  bone — Acute  periostitis  and  acute  osteomyelitis       .  609 

105.  The  chronic  inflammations  of  bone 618 

106.  Necrosis  of  bone 630 

107.  Spontaneous  (inflammatory)  separations  of  the  epiphyses        ....  637 

108.  Ehachitis 638 

109.  Osteomalacia 644 

110.  Atrophy  and  hypertrophy  of  bone 647 

111.  The  tumours  of  bone 653 

IV.  Injuries  and  Diseases  of  Joints. 

112.  Review  of  the  anatomy  of  the  joints 655 

113.  The  acute  inflammations  of  joints 658 

114.  The  chronic  inflammations  of  joints 667 

115.  Joint-bodies  or  joint-mice 687 

116.  Neuroses  of  joints  (neuralgias  of  joints;   nervous,  hysterical  diseases  of 

joints) 690 

117.  Neuropathic  diseases  of  bones  and  joints 693 

118.  Anchylosis 696 

119.  Deformities  of  joints  (contractures) 698 

120.  Injuries  of  joints 707 

121.  Sprains  (distortions) 708 

122.  Dislocations  of  joints 710 

123.  Wounds  of  joints 724 

Appetidix.     Gunshot  Wounds.     Military  Practice. 

134.  Gunshot  injuries 727 

V.   TUMOUES, 

125.  Tumours  in  general — definition  and  classification 738 

126.  Etiology  of  tumours 739 

127.  Growth,  course,  diagnosis,  and  treatment  of  tumours 742 

128.  The  different  varieties  of  tumours ;    connective-tissue   tumours  (fibroma, 

myxoma,  lipoma,  chondroma,  osteoma,  sarcoma,  etc.)        ....  746 

129.  The  epithelial  tumours  (papilloma,  epithelioma,  adenoma,  carcinoma,  etc.)   .  771 

130.  Cysts— Atheroma,  teratoma,  cyst-formation  in  different  tumours  .        .        .  784 


TILLMANNS'   PRINCIPLES   OF 
SURGERY   AND   SURGICAL   PATHOLOGY. 


FIRST  SECTIOX. 
GENERAL  PRINCIPLES  GOVERNING  SURGICAL  OPERATIONS. 


CHAPTER   I. 

THE    PREPARATIONS    FOR    AN    ASEPTIC    OPERATION. 

a.  Definition  of  a  surgical  operation,  b.  The  indications  and  counter-indications  for 
undertaking  an  operation,  c.  Antisepsis  and  asepsis,  d.  The  preparations  for  an 
aseptic  operation. — Operating  room. — Operating  table. — Preparation  of  the  patient. 
— The  operator  and  his  assistants. — Sterilisation  of  the  instruments. — Sponges. — 
Substitution  for  sponges  of  aseptic  (sterilised)  pads  of  gauze,  etc. — Preparation  of 
aseptic  dressings. 

vJcV*^  §  4.  Definition  of  a  Surgical  Operation. — An  "  operation,"  in  the 
broadest  sense  of  the  word,  means  any  meclianical  interference  of  tlie 
surgeon  undertaken  with  a  view  to  remedy  disease,  in  whicli  inter- 
ference snrgical  instruments  are  used.  ^ 
^  A  distinction  is  made  between  an  operation  in  whicli  a  loss  of 
y^  blood  occurs  and  one  in  which  it  does  not.  To  the  bloodless  opera- 
tions belong,  for  instance,  the  introduction  of  a  catheter  into  the 
bladder,  the  crushing  of  a  vesical  calculus  by  the  lithotrite,  the  re- 
moval of  foreign  bodies  from  the  external  auditory  meatus,  from  the 
pharynx,  etc. 

But,  generally  speaking,  an  operation  is  ordinarily  understood  to  be 
of  the  kind  that  is  accompanied  by  a  loss  of  blood,  and  this  is  the  kind 
that  is  meant  here.  "  Operative  surgery,"  says  Diffenbach,  "  is,  of  all 
branches  of  the  healing  art,  the  most  suited  to  arouse  enthusiasm  in 
its  followers ;  it  is  a  bloody  fight  with  disease  for  life — a  fight  that 
means  life  or  death." 

Every  surgeon  must  have  a  certain  amount  of  natural  talent,  and 
an  enthusiastic  devotion  to  his  profession.    A  complete  mastery  of  the 
2  U) 


2  THE   PREPARATIONS  FOR   AN   ASEPTIC   OPERATION. 

tecliiiiqne,  keen  senses,  a  well-trained  eye,  a  delicate  touch,  and  a  steady 
hand,  are  all  indispensable.  The  plan  of  the  operation  must  be  clearly 
mapped  out  beforehand,  and  during  the  operation  must  be  quietly  and 
resolutely  carried  out. 

§  5.  Indications  and  Counter-indications  for  an  Operation. — A  difficult 
problem  which  often  confronts  the  surgeon  is  to  correctly  weigh  the 
indications  and  counter-indications  for  undertaking  an  operation.  It 
is  often  a  hard  question  to  decide  whether  a  cure  is  not  possible  with- 
out an  operation ;  and  it  is  well  to  consider  whether  the  proposed 
operation  does  not  carry  with  it  greater  dangers  than  the  disease  itself, 
especially  in  those  cases  where  the  annoyances  are  but  slight.  The 
counter-indications  for  operation  depend  upon  the  particular  organ 
which  is  diseased  or  upon  the  general  condition  of  the  patient  (extreme 
youth  or  old  age,  general  weakness,  coexisting  acute  or  chronic  disease, 
etc.).  Under  all  circumstances  it  is  necessary  to  have  the  consent  of 
the  patient  for  the  proposed  operation. 

The  question  as  to  whether  an  operation  should  be  performed 
against  the  will  of  the  patient  is  answered  differently  by  different  sur- 
geons, though  the  majority  of  physicians  consider  that  they  are  entitled, 
and  indeed  obliged,  in  exceptional  cases,  to  perform  an  operation 
against  the  will  of  the  patient — if,  for  instance,  the  danger  from  the 
operation  is  much  less  than  that  from  the  continuation  of  the  disease, 
or  if  the  patient  can  be  saved  by  the  operation  from  certain  death. 

To  gain  the  desired  end  in  such  cases — or,  in  other  word.?,  to  per- 
form the  operation — the  patient  is  chloroformed,  and  upon  recovering 
from  the  anaesthetic  he  is  usually  glad  that  the  operation  has  been  done, 
even  though  contrary  to  his  will. 

§  6.  Preparations  for  an  Antiseptic  or  Aseptic  Operation. — We  operate, 
without  exception,  according  to  either  antiseptic  or  aseptic  principles — 
that  is,  we  try  to  prevent  entrance  into  the  wound  of  substan^'cs 
tliat  tend  to  cau.se  inflammation  and  j)utrefaction.  All  the  de- 
composing products  of  putrefaction  come  under  the  head  of  septic 
matter — sepsis  (from  cr?}-v/rt9)  meaning  putrefaction.  An  antiseptic 
method  of  conducting  an  operation  and  of  treating  a  wound  is  one 
that  is  directed  against  the  entrance  of  sepsis,  or  of  septic  rnaterial,  into 
the  wound,  or,  in  other  words,  prevents  infection  of  the  wound.  An 
uninfected  wound,  a  wound  which  runs  the  normal  course  in  healing, 
without  inflammation  or  suppuration,  is  called  aseptic — that  is,  it  is 
free  from  septic  materials. 

By  aseptic  is  meant  that  particular  mode  of  operating  and  treating 

a^wound  in  which  an  attempt  is  made  to  keep  septic  matters — i.  e., 

'  bacteria  and  the  poisonous  products  of  their  metabolism — out  of  \\\^ 


id.]  THE   PUEPAKATIONS   FOR   AX  ASEPTIC   OPEllATIOX.  3 

wouikI,  so  tliat  tlie  process  of  healing  inaj  he  without  iviictioiij  iiillaiii- 
ination,  supjjuration,  or  fever.  We  know  that  all  the  processes  of 
putrefaction,  that  (n^ery  infection  of  the  wound,  that  all  inflammation 
and  suppuration,  are  caused  by  niicro-oj-^inisms  (bacteria).  The  latter 
exist  everywhere ;  they  float  in  tlie  air,  where  they  are  mixed  with  the 
atmospheric  dust,  they  cling  to  the  clothes  and  the  skin  of  the  patient 
and  the  operator,  they  are  found  on  the  instruments,  sponges,  etc. 
Therefore,  if  we  wish  to  pi'otect  tliose  upon  whom  we  operate  from 
the  noxjous  influence  of  bacteria,  we  must  take  the  greatest  pains  to 
keep  the  latter  out  of  the  wound,  or,  if  they  have  already  found  lodg- 
ment in  the  body,  to  check  their  further  development,  and  to  destroy 
them  as  soon  as  possible. 

The  preparations  for  an  aseptic  operation  must  be  so  managed  that 
every  possibility  of  infecting  the  wound  is  avoided  l)y  careful  anti- 
septic rules.  Hence  we  must  always  take  pains  to  most  rigidly  disin- 
fect the  operating  room,  the  table,  the  part  to  be  operated  upon,  the 
hands  and  clothes  of  the  operator  and  his  assistants,  the  "instruments, 
sponges,  and  dressings — in  short,  everything  which  comes  into  direct 
or  indirect  contact  with  the  wound. 

Antisepsis  and  Asepis. — During  operations  in  former  times,  anti- 
septics were  employed  much  too  freely — for  instance,  in  the  form  of 
a  mist,  the  so-called  spray,  or  in  the  form  of  irrigations — and  at  the 
close  of  the  operation  the  wound  was  once  more  energetically  disin- 
fected. Our  most  effective  antiseptics,  especially  carbolic  acid  and  j 
bichloride  of  mercury,  are  poisonous,  and  many  patients  have  died  after 
the  operation  of  carbolic  and  bichloride  poisoning.  The  too  intense  irri-  7, 
tation  of  antiseptics  endangers  the  vitality  of  the  tissues  with  wliich  they 
come  in  contact,  and  rendersjthem  less  capable  of  withstanding  bacteria  ; 
furthermore,  serious  parenchymatous  lesions  are  thus  produced  in  opera-  ca- 
tions on  the  organs  in  the  thoracic  and  peritoneal  cavities  (Senger). 
It  is  right,  therefore,  to  limit  the  use  of  antiseptics  in  operations ;  in 
fact,  most  surgeons  aim  to  avoid  them  entirely.  Disinfection  and  anti- 
septic treatment  of  a  fresh  wound  which  has  been  made  by  the  surgeon 
is  not  necessary  if  the  operation  is  conducted  strictly  aseptically — that 
is,  if  the  field  of  operation,  the  hands  of  the  surgeon,  the  instruments, 
the  sponges  or  gauze  pledgets,  etc.,  have  been  sterilised — i.  e.,  rendered 
free  from  micro-organisms.  Under  such  conditions  a_stmlised  solu- 
tion of  common  salt  of  a  strength  of  five  tenths  to  seven  tenths  per 
cent.,  or  boiled  water,  can  be  substituted  for  the  carbolic  or  bichloride 
solutions.  If  larger  amounts  of  sterilised  water  are  needed,  the  ap- 
paratus of  Fritsch  is  useful.  The  employment  of  a  six-tenths-per-cent.  ,<^  cj^a 
sterilised  salt  solution  is  especially  useful  in  laparotomies  (Fritsch). 


4  THE   PREPARATIONS   FOR  AN   ASEPTIC   OPERATION. 

Aspjjsis  has  taken  the  place  of  antisejosis  in  operatioyisAor  the  rea- 
son tliat  a  wound  which  lias  not_been  irritated  hy  antiseptics^Jieals 
much  more  readilyj'^'the  secretion  is  much  less,  and'^drainage  can  more 
frequently  be  entirely  dispensed  with.  Furthermore/the  process  of 
repair  in  the  wound  is  quicker  with  the  aseptic  than  with  the  antiseptic 
method;"^ the  aseptic  cicatrix  forms  sooner,  and  is  more  solid  and 
durable  than  when  the  wound  has  been  irritated  by  antiseptics.  "When 
the  latter  have  been  used  the  process  of  cell  division  is  more  sluggish, 
and  begins  later. 

In  the  case  of  wounds  treated  by  the  aseptic  method,  complete 
healing  and  the  formation  of  the  cicatrix  usually  occupies  eight  days ; 
while  in  wounds  in  which  bichloride  of  mercury  has  been  nsed  the 
change  from  granulation  to  cicatricial  tissue  has  hardly  begun  in  this 
time. 

Socin,  Bergmann,  Xeul)er,  and  others,  were  among  the  first  to 
give  up  antisepsis  for  asepsis,  though  Lawson  Tait,  and  Koberle  had 
long  furnished  proof  that  beautiful  operative  results  could  be  obtained 
without  using  antiseptic  solutions.  But  for  injuries  and  wounds  already 
infected,  the  rules  of  rigorous  antisepsis  are  to  be  carried  out — i.  e.,  the 
wound  should  be  thoroughly  disinfected  with  a  three-  to  five-per-cent. 
solution  of  carljolic  acid  or  a  one  tenth  to  one  fiftieth  per  cent,  of  bi- 
chloride of  mercury.  At  present,  for  the  same  reasons,  there  is  a  dis- 
position to  ayT)id  the  use  of  dressings  impregnated  with  antiseptic 
materials,  such  as  carbolic  acid  and  bichloride,  as  the  dressings  can  be 
most  easily  and  surely  disinfected  by  subjecting  them  to  the  action  of 
steam  at  a  temperature  of  100°  to'  130°  C.  (212°  to  200°  F.)  for  a 
half  to  three  quarters  of  an  hour.  This  method  of  disinfection  is 
much  surer  than  when  the  dressings  are  impregnated  with  antiseptic 
materials,  as  in  dressings  thus  impregnated  bacteria  have  been  detected 
after  a  short  time.  Steam  sterilising  apparatus  have  now  been  uni- 
versally introduced  in  hospitals  for  the  treatment  of  dressings,  operat- 
ing gowns,  beds,  bed-clothing,  etc.,  and  small  steam  sterilising  apparatus 
can  easily  be  brought  into  every  large  surgical  ward.  The  portable 
steam  sterilisers  of  Straub,  H.  Settegast,  Bubenberg,  E.  Hahn,  and 
Schimmelbusch  are  especially  adaptable  for  private  practice.  In  Fig.  1 
is  illustrated  the  steriliser  of  Schimmelbusch,  which  has  been  intro- 
duced in  Bergmann's  clinic. 

As  regards  the  mechanism  of  this  apparatus,  the  following  should 
be  noted  :  IF,  the  part  which  holds  the  water,  is  filled  by  a  funnel 
through  the  tube  T,  up  to  a  marked  height.  Whatever  is  to  be  sterilised 
is  placed  in  the  inner  compartment  of  the  apparatus,  the  latter  having 
a  double  metallic  wall.     The  cover  D  is  screwed  on  tio^ht.     In  the 


g«-J 


THE    PKEPAliATlUXS   FOR  AX   ASEPTIC   OPERATION. 


centre  of  the  cover  is  j)laced  the  thermometer,  Tli.  The  water  is  heated 
by  a  gas  Hame,  and  the  steam,  at  a  temperature  of  100°  to  130°  C. 
(212°  to  200°  F.),  enters  the  inner  com- 
partment of  the  apparatus  from  above,  and 
escapes  through  the  opening  R  into  a  lead 
spiral  in  a  condenser  tilled  with  water.  The 
air  between  the  double-walled  water  vessel 
and  the  metallic  enclosure,  w'hich  is  protected 
by  asbestos,  escapes  through  the  openings  at 
O.  At  the  end  of  the  sterilisation  the  water 
can  be  drawn  off  through  the  faucet  ZT,  the 
cover  is  removed,  and  the  sterilised  article 
taken  out.  In  order  that  the  sterilised  dress- 
ings can  be  kept  sterile,  the  tin  vessel  devised 
by  Schimmelbusch  (Fig.  2)  is  used.  This  is 
provided  with  a  tight  cover  {d)  and  a  great 
number  of  holes  {a  h) ;  the  latter  can  be 
opened  and  closed  at  will  by  a  strip  of  tin. 
This  tin  vessel  is  filled  with  dressings  and 
placed  in  the  steriliser. 

We  shall  return  again  to  the  subject  of 
sterilisation  of  the  dressings,  operation  gowns, 

compresses,  etc.,  and  presently  describe  the  sterilisation  of  the  instru- 
ments by  boiling  for  five  minutes  in  a  one-per-cent.  soda  solution,  the 
cleansing  of  the  hands,  etc.  For  the  disinfection  of  large  articles, 
such  as  mattresses,  clothes,  etc.,  the  disinfector  of  Kietschel  and 
Henneberg  is  particularly  good.  The  cleanliness  of  the 
operating  room  and  of  everytliing  it  contains  must  always 
be  rigorously  enforced  by  the  surgeon. 

Operating  Room. — The  operating  room  should  be  as 
light  as  possible,  well  ventilated,  and  plentifully  sup- 
plied with  arrangements  for  washing,  receptacles  for 
disinfecting  solutions,  especially  three-to  five-per-cent. 
solutions  of  carbolic  and  bichloride  (1  to  1,000-5,000),  etc. 

In_larger  hospitals  it  is  well  to  have  two  operating 
rooms,  one  for  aseptic  operations  and  the  other  for  in- 
fected cases ;  and  it  is  advantageous  to  have  on  the  floor 
of  the  operating  room,  which  is  best  made  of  cement,  a 
gutter  arrangement  for  conducting  o£E  the  water. 

The  walls  of  the  operating  room  must  be  so  built  as  to  be  capable 
of  being  easily  and  thoroughly  cleansed,  and  therefore  should  be  cov- 
ered with  oil  or  enamel  paint,  or  with  metal  oi"  glass  plates.     Recesses 


Fig.  1. — Steani-sterilisiug  appara- 
tus (Lauteusciiliiger.) 


Fig.  2.  —  Sheet- 
iron  vessel  for 
dressing  mate- 
rials (Scliim- 
melbusch). 


6 


THE   PREPARATIOxWS   FOR  AN   ASEPTIC   OPERATION. 


and  corners  wliicli  can  harbour  dust,  etc.,  are  to  be  avoided,  on  account 
of  the  microbes  they  contain,  and  pains  sliould  be  taken  not  to  stir  up 
dust  eitlier  before  or  during  the  operation.  Before  an  operation  tlie 
air  in  the  room  can  be  moistened  by  steam  from  a  large  spray  or  steam 
pipe,  if  there  is  one,  and  thus  freed  of  dust. 

Operating  Table. — The  operating  table  should  be  as  simple  as  pos- 
sible and  absolutely  clean.     In  order  to  facilitate  the  escape  of  soiled 


Author's  operating  table. 


liquids,  operating  tables  are  coming  more  and  more  into  use  which  are 
])rovided  with  means  to  carry  off  these  fluids.  Juillard,*  Sprengel,t 
Paul  Schede,:}:  and  Hagedorn  *  have  invented  excellent  operating  tables, 
with  receptacles,  buckets,  etc.,  placed  under  the  table  to  receive  the 
overflow.  I  consider  the  operating  tables  used  by  Paul  Schede, 
Hagedorn,  and  Bergmann  worthy  of  reconnnendation  in  every  way. 
Operating  tables  made  with  an  iron  frame  and  a  glass  plate  are  very 
good.  My  own  operating  table,  illustrated  in  Fig.  3,  has  an  iron 
frame  with  a  plate  of  strong  flint  glass ;  the  gutter  placed  around  the 
table  conducts  away  the  overflow  into  a  vessel  underneath,  and  the 
whole  table  can  be  readily  cleaned.  The  head-piece,  which  is  easily 
adjusted,  is  fitted  with  a  removable  glass  plate.  For  elevating  the 
pelvis,  a  movable  framework  can  be  brought  into  use,  made  like  the 
head-piece,  of  glass  and  iron,  and  leg-supporters  can  be  very  easily 


*  lllust.  Monatscht.  d.  Arz.  Polytec,  1883,  lleft  13.      t  Clentrl.  f.  Chir.,  1886,  No.  8. 
t  Centrl.  f.  Chir.,  1884,  No.  30.  »  Ibid.,  1887,  No.  28. 


§«•] 


THE   PREPARATIONS   FOR  AN   ASEPTIC   OPERATION. 


Fio.  4.— Author's  transportable  operating  tauio  for  private  and 
military  practice. 


attached.     I  liave  also  devised  a  transportable  table  with  folding  legs 
for  private  practice  and  for  army  use  (Figs.  4,  5,  0),  which  is  made  of 
wrought   iron,    weighs 
only   twenty-live    kilo- 
grammes, and  is  inex- 
pensive, 

Trendelenburg  has 
constructed  a  table 
which  allows  the  pa- 
tient to  be  brought  into 
various  positions.  For 
protracted  o])erations 
— laparotomies,  for  in- 
stance— it  is  advanta- 
geous to  use  operating 
tables  which  can  be 
kept  warm,  such  as  me- 
tallic tables  (Socin) 
filled  with  hot  water. 
In  this  way  the  patient 
is  kept  from  losing 
too  much  body  tem- 
perature. 

Preparation  of  the 
Patient. — The  prelimi- 
naries for  an  operation 
begin  with  the  prepa- 
ration of  the  patient. 
In  operations  of  any 
magnitude  the  whole 
body  should  be  first 
thoroughly  cleansed  by 
means  of  a  warm  bath, 
after  which  the  part  of 
the  body  to  be  oper- 
ated on  is  scrubbed  with  soft  soap,  shaved,  rubbed  off  with  ether 
to  remove  the  fat  on  the  skin,  and  washed  with  a  three-to  five- 
per-cent.  solution  of  carbolic  acid,  or  an  aqueous  solution  of  bi- 
chloride of  mercury  of  a  strength  of  1  to  1,000-1  to  5,000.  The 
scrubbing  and  disinfecting  of  the  hands  and  feet  especially  must  be 
thoroughly  and  carefully  carried  out.  Instead  of  brushes  which 
are  boiled  and  kept  in  a  bichloride  solution  (1  to  1,000),  I  use  swabs 


Fm.  5. — Method  of  folding  up  the  table. 


Fig.  6.- 


-The  transportable  operating  table :   a,  seen  from  be- 
low ;  /»,  the  side ;  c,  the  end. 


8  THE  PREPARATIONS  FOR  AN  ASEPTIC  OPERATION. 

of  wood  fibre  or  cotton  wliieli  are  sterilised  by  heat  and  burnt  after 
use. 

In  operations  in  tlie  mouth  the  teeth  should  be  thoroughly  cleansed 
by  a  toothbrush,  and  the  mouth  frequently  rinsed  with  a  chlorate-of- 
potash  solution  of  a  strength  of  5  or  6  to  100,  or  permanganate  of 
potassium,  boric  acid,  etc.  Carious  teeth  and  the  tartar  which  swarms 
with  bacteria,  etc.,  are  to  be  removed.  If  the  operation  is  in  the  hypo- 
gastric region,  in  the  neighbourhood  of  the  anus,  on  the  urinary  and 
sexual  organs,  or  in  the  peritoneal  cavity,  care  should  be  taken  to 
secure  a  movement  of  the  bowels  on  the  last  day  before  the  operation 
by  a  dose  of  castor  oil,  and  about  two  hours  before  the  operation  the 
rectum  should  be  washed  out  with  lukewarm  water  injected  from  an 
irrigator.  When  necessary,  the  bladder  should  be  emptied  in  advance 
by  a  catheter. 

The  stomach  of  a  patient  about  to  be  chloroformed  should,  if  pos- 
sible, be  empty,  and  in  all  cases  the  taking  of  solid  food  shortly  before 
the  operation  should  be  forbidden,  so  that  the 
respiratory  movements  of  the  diaphragm  shall 
not  be  interfered  with,  and  troublesome  vomit- 
ing shall  not  occur.  The  entrance  of  vomited 
matter  into  the  air  -  passages  has  repeatedly 
caused  death  during  chloroform  narcosis. 

After  the  cleansing  and  disinfecting  of  the 
portion  of  the  body  to  be  operated  upon  has 
been  completed,  the  patient  is  then  covered  with 
rubber  or  linen  protectives,  leaving  the  field 
of  operation  exposed  (Figs.  T-10).  For  this 
purpose  protectives  are  provided  with  openings 
Fig.  r.-Preparation  of  the  ^^^'  the  arms,  legs,  and  neck,  or  they  are  suitably 
patient  for  operations  on   fastened  together  with  safety  pins.     The  linen 

the  face  and  neck.  ~  .  . 

protectives  should  be  sterilised  by  keeping 
them  for  half  an  hour  in  the  steriliser  at  a  temperature  of  100°  C. 

In  operations  upon  the  face  and  neck  the  patient's  hair  should  be 
covered  by  a  rubber  cap,  which  is  made  to  fit  tightly  by  means  of  an 
elastic  band,  so  as  to  prevent  the  hair  from  coming  in  contact  with 
the  field  of  operation ;  or,  better  still,  the  head  may  be  wrapped  in  an 
aseptic  gauze  bandage. 

For  operations  in  the  peritoneal  cavity,  it  is  better  to  provide  two 
protectives,  as  is  shown  in  Fig.  10.  Figs.  7  to  10  illustrate  sufficiently 
the  excellent  plan  which  has  been  recommended  by  Neuber.  I  cover 
the  neighbourhood  of  the  field  of  operation  with  large  aseptic  cam- 
presses  (or  towels)  which  have  been  sterilised  in  the  steriliser  by  heat 


Ji<>-J 


THE   PREPARATIONS   FOR  AN    ASEPTIC   OPERATION. 


9 


Fig.  8.— Position  of  the  patient  in  operations  on  the  upper  ex- 
tremity. 


a^  teinpe  nit  lire  of  100°  to  130°  C.  (212°  to  234°  F.),  and  are  then 
moistened  with  a  one-tenth-per-cciit.  sohition  of  bicliloride. 

If  an  operation  is  protracted,  especially  in  cold  weather,  care  must 
be  taken  that  the  patient  does  not  become  chilled.  If  the  patient  be- 
comes badly  chilled,  a 
dangerous  or  even  fa- 
tal collapse  may  be  pro- 
duced, especially  after 
operations  in  the  peri- 
toneal cavity.  For  this 
reason  it  is  wise  to  pro- 
tect the  patient  by  flan- 
nel coverings,  warm 
cloths,  etc.,  and  partic- 
ularly by  warming  the 
operating  room  to 
about  "16°-1S°-19°  E. 
{C,S°  to  75°  F.).  For 
protracted  operations 
the  warmed  operating 
table  of  Socin,  already 
mentioned,  is  valuable. 

The  best  clothing 
for  the  operator  and 
his  assistants  consists 
of  a  linen  operating 
gown,  the  sleeves  of 
which  only  reach  to 
the  middle  of  the  up- 

l)er  arm.     Before  every    Fig.  lO. — Position  of  the  patient  in  operations  in  the  abdominal 
.  '  c       1  cavity. 

operation     the     fresli- 


Fic 


y.— Position  of  the  patient  in  operations  on  the  lower  ex- 
tremity. 


1$ 


ly  washed  operating  gowns  are  sterilised  for  a  half  to  three  quarters  of 
an  hour  in  the  steriliser  by  the  action  of  hot  steam  at  a  temperature  of 
100°  C.  (212°  F.).  With  a  view  to  preserving  thorough  asepsis,  the 
operator  and  his  assistants  must  work  with  bare  forearms. 

The  hands  and  forearms  are  disinfected  in  the  following  manner 
(P.  Fiirbringer) :'  wliile  dry,  the  nails  are  iirst  cleansed  of  visible  dirt  by 
a_jiail  cleaner  and  scissors  which  are  always  kept  in  a  ten-per-cent. 
solution  of  carbolic  acid  in  glycerine ;  ''then_the  hands  and  forearms 
are  thoroughly  scrubbed  with  a  brush  in  soap  and  warm  water,  with 
special  attention  to  the  ends  of  the  fingers  and  the  part  underlying 
the  nails, 'then  rubbed  for  one  minute  in  seventy  to  eiglity  per  cent. 


10 


THE   PREPARATIONS   FOR  AN  ASEPTIC   OPERATION. 


alcoliol,  and  befoi-e  tlie  alcoliol  has  evaporated  tlie  liands  and  forearms 
are  scrubbed  with  a  brush  for  one  minute  in  a  1  to  J^OU  solution  of 
bichloride  or  a  three-per-cent.  solution  of  carbolic. 

It  is  of  the  greatest  importance  in  the  disinfection  of  tlie  hands  to 
make  the  mechanical  cleansing  of  the  latter  as  thorough  as  possible. 
This  is  in  accord  with  the  researches  of  Landsberg.  For  keeping  the 
hands  in  a  good  condition  Pears's  glycerine  soap  is  particularly  useful, 
and  if  anything  more  is  necessary,  the  inunction  of  a  small  amount  of 
lanolin  is  excellent.  The  modern  surgeon  should  give  up  wearing 
rings,  and  in  any  case  always  lay  them  aside  before  an  operation,  as 
they  are  invariably  bearers  of  infection.  A  large  basin  containing^  a 
three-per-cent.  solution  of  carbolic  or  a  1  to  1,000  solution  of  bichloride 
should  be  placed  near  the  operator  and  his  assistants,  so  that  they  may 
constantly  keep  their  hands  disinfected,  even  though  they  do  not  come 
in  contact  with  unclean  objects,  such  as  pus,  fasces,  urine,  etc. 

Sterilisation  of  Instruments. — The  instruments  are  best  disinfected 

^f^     by  boiling  them  for  live  to  ten  minutes  in  a  one-per-cent.  solution 

of  soda,  the  latter  substance  rendering  them  less  liable  to  rust  than 

plain  water.     According  to  Davidsohn,  five  minutes  is  sufficient.     The 

knives  are  wiped  off  with  a  piece  of  sterilised  cotton  wet  in  carbolic 

solution  and  placed  for  only  one 
minute  in  the  boiling  soda  solution, 
as  they  are  easily  dulled.  As  wood- 
en handles  on  instruments  are  soon 
damaged  by  boiling,  nickel-plated 
metal  handles  are  preferable. 

Instruments  are  not  sufficiently 
disinfected  by  simply  placing  them 
in  carbolic  or  other  antiseptic  solu- 
tion (Giirtner,  Kummel,  Gutsch, 
Redard,  Davidsohn).  A  sterilising 
apparatus  for  instruments  can  l)e 
made  for  a  small  price  by  any  tin- 
man, in  the  follov/ing  manner :  a 
large  box  made  of  sheet  cop])er, 
with  a  removable  top,  is  provided 

Fig.  11.— Apparatus  for  boiling  instruments     with     a    tray    of    tin    plate    whicll    is 
(Scbimmelbusch).  i      i     i;    ii        f     i     i  ^\         * 

punched  full  of  holes ;  tiie  tray 
holds  the  instruments,  and  has  two  handles  attached  to  it  so  that  it  can 
be  lifted  out  after  the  boiling  and  placed  in  a  three-per-cent.  solution  of 
carbolic  acid.  A  very  excellent  apparatus,  devised  by  Schimmelbnsch, 
is  illustrated  in  Fig.  11,  but  it  is  much  more  expensive.     The  figure 


§6.]  THE   ntKPARATlUNS    FOR   AN    ASEPTIC   OPERATION.  ]  l 

needs  no  explanation.  At  the  close  of  tlie  process  of  sterilisation  the 
wire  tray  E,  which  holds  the  instruments,  is  taken  out  and  placed  in  a 
three-per-cent.  carbolic  solution  contained  in  a  glass  dish  or  tray  made 
of  enamel-covered  metal. 

Before  using,  I  generally  Nvipe  off  every  knife  carefully  with  a 
p_iece  of  sterilised  cotton  moistened  in  a  three-per-cent.  solution  of 
carbolic  acid.  This  is  a  mechanical  means  of  disinfection  which  Gartner 
has  shown  to  be  particularly  efficacious.  During  the  operation  the 
instruments  should  lie  in  an  antiseptic  solution,  preferably  a  three-per- 
cent^solution  of  carbolic.  Fur  this  purpose  trays  are  used  made  of 
glass,  porcelain,  and  metal.  The  Tion-breakable  and  easily  cleaned 
vessels  of  enamelled  metal  which  are  used  in  the  kitchen  are  very  good 
for  this  purpose.  After  every  operation  the  instruments  are  scrubbed 
with  a  brush  and  soap  in  a  three-per-cent.  solution  of  carbolic  acid  and 
then  polished. 

Amongst  the  other  sterilising  apparatus,  those  devised  by  Braatz, 
Kronacher,  Sternberg,  and  Mehler  should  be  mentioned 

For  sponging  the  wound  during  the  operation,  sterilised  pledgets  of 
cotton  wool  or  gauze  pads  should  be  used,  and  these  are  kept  wrapped 
uj)  in  sterilised  gauze  ;  they  are  made  germ-free  by  sterilisation  at  a  tem- 
perature of  1U0°  to  130°  C.  (212°  to  266°  F.j  for  half  an  hour,  and  are 
decidedly  preferable  to  the  ordinary  sponges  which  were  formerly  em- 
ployed, as  the  pads  are  only  used  to  wipe  out  the  wound  once  and  are 
afterwards  burnt.  A  large  stock  of  such  sterilised  gauze  pads  can  be 
always  kept  on  hand  in  a  bichloride  solution  (1  to  1,000),  or  only  freshly 
sterilised  pads  can  be  used. 

Disinfection  of  Sponges. — Ordinary  sponges  very  quickly  become  use- 
less after  steiilisation  in  the  hot  steam  of  a  steriliser,  and  they  are  best 
disinfected  in  the  following  way :  After  pounding  them  thoroughly, 
rinse  them  in  a  solution  of  potassium  permanganate  (1  to  500-1,000), 
then  soak  them  for  a  quarter  of  an  hour  in  a  solution  consisting  of 
four  fifths  to  one  per  cent,  of  hyposulphite  of  soda  and  from  one  fifth 
to  eight  per  cent,  of  pure  hydrochloric  acid  (Keller) ;  then  place  them 
for  a  quarter  of  an  hour  more  in  boiling  water  or  in  a  boiling  soda 
solution  of  a  strength  of  one  per  cent.  The  sponges  are  stored  in  a 
five-per-cent.  solutiqn__of_jcaTb^lic  acid_jor_0_ne-tenth  per-cent.  solution 
of  bichloride  of  mercury. 

Sterilisation  of  Dressings,  Silk,  Catgut. — Silk,  catgut,  drainage-tubes, 
dressings,  and  bandages  should  also  be  rendered  perfectly  sterile. 
Silk  should  be  boiled  for  half  an  hour  in  a  bichloride  solution  (2  to 
1,000)  or  a  five-per-cent.  carbolic  solution,  and  the  other  materials  can 
be  treated  l)y  dry  sterilisation — i.  e.,  by  keeping  them  in  the  dry  steril- 


12 


THE   PREPARATIONS   FOR  AN   ASEPTIC   OPERATION. 


iser  .for  half  an  hour  at  a  temperature  of  100°  C.  (212°  F.). 
sterilisation  of  catgut,  see  page  88. 


For  the 


^^5^ 


Fig.  12. — Hand-spraying  apparatus. 


The  Spray. — Some  years  ago  the  operation  and  the  ai)]j]ication  of  the 
dressings  were  alvv ays  carried  out  under  the  Lister  si)ray—iu  other  words,  in  a 

fine  mist  of  carbolic  acid.  The  man- 
agement of  tiae  hand  spray  can  be  un- 
derstood without  further  explanation 
from  the  illustration  in  Fig.  12.  The 
steam  spray  apparatus  consists  of  a 
vessel  containing  water,  with  a  spirit 
lamp  underneath.  The  boiler  is  filled 
through  the  opening  at  a  and  then 
closed  by  a  stopper  which  is  screwed 
in  place.  At  b  is  placed  a  safety  valve, 
which  allows  the  steam  collected  in 
the  kettle  to  escape  in  case  the  cock 
at  c  is  turned  off.  The  steam  passes 
from  the  boiler  through  a  tube  closed 
and  opened  by  the  cock  c,  then  into  a  glass  containing  three  to  fl.ve  per  cent. 
carbolic  acid,  and  diives  the  latter  out  of  the  end  of  the  tube  in  the  form  of 
a  spray,  the  direction  of  which  can  be  changed  by  means  of  the  handle  d. 

At  present  the  spray,  as  has  been  said,  is  seldom  employed,  and  I,  person- 
ally, never  use  it.  It  has  been  proved  that  the  results  obtained  without  the 
spray  are  just  as  good  as  those  obtained  with  it.     The  spray  is  troublesome, 

inconvenient  for  the  operator,  and 
not  free  from  danger  to  the  patient 
on  account  of  the  not  unimportant 
chilling  it  may  cause,  and  from  the 
danger  of  carbolic  or  bichloride 
poisoning.  I  sometimes  use  the 
spray  before  a  laparotomy  when  I 
wish  to  purify  the  air  of  the  operat- 
ing room,  and  for  this  purpose  I 
use  a  steam  spray  placed  as  high  up 
as  possible.  In  hospitals  fitted  with 
steam  or  water  pipes  a  very  effective 
spray  apparatus  can  be  contrived  by 
connecting  the  steam  pipe  with  the 
boiler  of  the  apparatus,  and  in  this 
way  the  air  in  the  operating  room 
can  be  very  easily  and  cheaply  ren- 
dered germ  free — in  other  words,  disinfected. 

The  disinfection  of  the  air  of  the  operating  room  is  ordinarily  not  neces- 
sary, since,  in  reality,  wounds  are  only  infected  by  contact  with  the  microbes 
on  unclean  and  insufficiently  disinfected  hands,  dressings,  and  instruments, 
but  not  by  the  bacteria  in  the  air  (Ktimmel,  P.  Fiirbringer).  I  lay  great 
stress  upon  covering  the  neighbourhood  of  the  field  of  operation  with  steril- 
ised towels,  dipped  in  a  one-tenth  per  cent,  solution  of  bichloride  of  mercury. 


Fig.  13.— Steam 


l>ru\  Hi 


§6.] 


THE    PRKPAUATIONS   FOR   AN    ASEPTIC   OPERATION. 


13 


Preparation  of  the  Dressings.— I  should  mcutiou  that  tlie  aseptic  cov- 
erings of  the  wuuiul,  dressings,  handages,  etc. — sterilised  by  heating 
them  at  a  temperature  of  100°  C  (212°  F.) — are  made 
ready  in  advance.  We  shall  speak  of  these  in  Chap- 
ter II.  (The  Techni(pie  of  applying  Dressings). 


^ 


Preparations  for  Operations  in  Private  Practice.— If 

an  operation  is  to  be  conducted  aseptically  outside  of  a 
clinic  or  hospital,  as  large  and  li<2;']it  a  room  as  possible 
should  be  selected,  and  thorouo-lily  cleaned  and  aired. 
The  surest  and  simplest  way  of  disinfecting  a  room  is  to 
rub  down  the  walls  and  ceiling  with  bread  (E.  von  Es- 
march),  though  infected  rooms  can  also  be  disinfected  by 
,burniug  sulphur  after  the  rooms  have  been  tightly  closed. 
A  table,  on  which  to  place  the  patient,  should  be  pro- 
vided, and  covered  with  some  water-tight  material  and 
then  with  sterilised  linen ;  and  two  or  three  other  tables 
should  be  near  by,  likewise  covered  with  stei'ilised  linen, 
to  hold  the  instruments,  dressings,  and  wash-basins. 

Several  wash-basins,  soap,  absolute  alcohol,  brushes, 
towels,  sterilised  dishes  for  the  instruments,  and  sponges 
should  be  witlun  reach,  as  well  as  warm  sterilised  water 
in  large  quantities,  chloroform  or  ether,  concentrated  car- 
bolic solution,  tablets  of  bichloride,  aseptic  sponges  or  gauze  pads,  drains, 
silk,  catgut,  and  the  necessary  instruments  stei'ilised  by  boiling  in  a  one  per- 
cent, soda  solution,  and  dressings  and  bandages. 

Silk  and  catgut  can  be  carried  about  very  easily  in  the  sitnple  apparatus 
pictui'ed  in  Fig.  14. 


Fig.  14. — Metallic  or 
hard-rubber  ease 
with  spool  for 
aseptic  catgut  and 
silk. 


CHAPTER   II. 

THE    ALLEVTATIOX    OF    PAIN    DURING    OPERATIONS. NARCOSIS. LOCAL 

AN.ESTHESIA. 

Hi-story. — Chloroform. — The  physiological  action  and  the  method  of  administering 
chloroform. — .Symptomatology  of  chloroform  narcosis. — The  possible  accidents 
during  chloroform  narcosis :  death  from  chloroform. — Treatment  of  the  possible 
accidents  during  chloroform  narcosis. — Other  anjesthetics :  methyl  compounds. — 
Ether. — The  phenomena  of  ether  narcosis. — Method  of  administering  ether. — The 
remaining  ether  compounds. — Nitrous  oxide  (laughing  gas)  as  an  anaesthetic. — 
Other  anaesthetics. — Mixed  narcosis. — Local  ana-sthesia. 

§  7.  The  Alleviation  of  Pain  during  the  Operation. — A  distinction  is 
made  between  general  antestlie.-ia — i.  e.,  narcosis  which  is  caused  by  the 
inhalation  of  some  sleep-producing  vapour  or  gas — and  the  local  anaesthe- 
sia which  is  limited  to  a  particular  portion  of  the  body,  and'  produced 
by  the  local  application  of  a  substance  to  the  part  of  the  body  to  be 
operated  upon. 

Since  the  earliest  times  attempts  have  been  made  to  perform  opera- 
tions with  the  aid  of  some  means  for  allaying  pain,  but  the  methods 
were  invariably  bad,  and  the  action  of  the  remedies  which  were  tried 
was  insufficient.  It  was  not  till  the  year  1840.  with  the  introduction 
of  ether  as  an  anaesthetic,  that  the  dream  of  the  old  surgeons  was  to 
come  true — namely,  the  performance  of  even  major  operations  without 
pain. 

As  early  as  the  year  1800,  Humphry  Davy,  reasoning  from  his 
numerous  physiological  experiments,  had  recommended  nitrous  oxide 
(laughing  gas)  as  an  anfesthetic  ;  and  Horace  Wells,  a  dentist  in  Hart- 
ford, tested  the  remedy  in  1844  by  extracting  twelve  or  fifteen  teeth  ; 
but  he  was  not  able  to  introduce  the  drug  as  an  anjesthetic  into  gen- 
eral surgical  practice. 

In  ancient  times  cannabis  indica  and  opium  were  the  chief  remedies  for 
controlling  pain.  Besides  these,  the  pulverised  stone  of  Memphis  was  used  — 
a  kind  of  marble  which,  when  treated  with  acetic  acid,  gives  ofP  carbonic  acid 
and  in  this  way  produces  a  certain  amount  of  local  aneesthesia.  Mandrake 
root,  made  into  a  decoction  with  wine,  was  also  given  internally,  and  was 
used  especially  by  the  ancient  Greek  physicians,  and  in  fact  was  employed 

(14) 


«^:.|         THE   ALL?]V1ATI0N    OF   PAIN    DURING    THE   OPERATION.  ir, 

during  the  middle  ages  till  the  end  of  the  sixteenth  eentury.  In  the  middle 
ages  patients  were  often  made  to  inhale  vapours  made  from  hemlock  and 
from  the  juiee  of  the  mandrake  leaf.  Of  interest  in  this  connection  are  the 
experiments  of  Theodoric  of  Cervia,  a  learned  Dominican,  who  at  his  death, 
in  1298.  was  Bishop  of  Bologna.  A  celehrated  surgeon  of  Salerjio,  Mazzeo 
della  Montagna  (KJOD-l.'ilO),  is  said  to  have  given  the  patients  whom  he  was 
about  to  operate  upon  some  sleep-jn'oducing  potion.  Porter  also  speaks  of  a 
remedy,  without  describing  it  more  exactly,  which,  when  inhaled,  brought 
on  a  deep  sleep. 

Besides  these  methods,  excessive  blood-letting  till  fainting  occurred,  com- 
pression of  the  vessels  and  nerves  (Moore),  enormous  doses  of  tartar  emetic, 
electricity,  animal  n:iagnetism,  and  hypnotism  have  all  been  tried.  On 
April  8,  1829,  Cloquet  is  said  to  have  I'emoved  without  pain  a  cancer  of 
the  breast,  together  with  the  axillary  glands,  from  a  fourteen-year-old  girl 
during  the  magnetic  sleep,  and  in  1842  Ward  amputated  a  thigh  under  the 
same  conditions.  Guerineau  also  performed  a  painless  amputation  of  the 
leg  while  the  patient  was  in  the  hypnotic  slumber. 

Manj^  other  attempts  were  made  to  perform  operations  painlessly  during 
the  hypnotic  state,  but  they  were  seldom  successful ;  and  Kappeler  is  certainly 
right  when,  in  explaining  the  above-mentioned  magnetic  or  hypnotic  anaes- 
thesia, he  calls  to  mind  that  thei*e  are  individuals  whose  sensibilities  are  ab- 
normally bkuited,  and  that  insensibility  can  be  simulated. 

Two  Americans — the  cliemist  Charles  Jackson,  and  the  dentist 
W.  T.  G.  Morton — introduced  ether  as  an  anaesthetic  into  general  sur- 
i^'al  use,  after  tlie  inhalation  of  ether  had  ah-eady  been  used  by  others 
to  allay  pain  and  the  pliysiological  action  of  tlie  vapour  was  known. 
Furthermore,  in  1842  and  1843,  Dr.  C.  W.  Long,  of  Athens,  Georgia, 
liad  anaesthetised  several  patients  with  ether  without  publishing  his  ob- 
servations. Morton  induced  AVarren,  the  surgeon  of  the  Massachusetts 
Hospital,  to  try  the  new  remedy,  and  the  latter,  on  October  17,  1846, 
i-emoved  without  pain  a  tumour  of  the  neck  under  ether  narcosis.  The 
knowledge  of  the  new  discovery  spread  quickly  to  Europe — first  to 
England,  then  to  France,  Germany,  and  the  other  countries.  In  Eng- 
land, Robinson,  Liston,  and  Simpson  were  the  first  to  try  it,  and  they 
were  followed  by  Malgaigne  in  France.  Schuh  was  the  first  in  Ger- 
many, and  on  January  27,  1847,  he  removed,  without  pain,  a  telean- 
geiectasjs  during  ether  narcosis. 

But  the  supremacy  of  ether  as  an  anaesthetic  was  not  to  continue 
long.  In  November,  1847,  Simpson,  as  a  result  of  some  eighty  obser- 
vations, including  surgical  and  labour  cases,  recommended  chloroform, 
which  had  already  been  discovered  in  1831  by  Soubeiran,  in  Paris,  and 
had  lain  unnoticed  on  the  apothecary's  shelves  for  sixteen  years. 
Ether  was  very  quickly  superseded  by  chloroform,  and  the  enthusiasm 
for  the  new  remedy  was  tremendous.     But  soon  the  first  deaths  from 


16  THE    ALLEVIATION   OF   PAIN   DURING    OPERATIONS. 

chloroform  ■were  reported,  and  the  wish  for  a  new  ana?sthetic  became 
active.  Nmnerons  other  drugs  were  tried,  but  at  the  present  day  chlo- 
.roform  and  ether  hold  the  field  in  triumph  without  rivals  worthy  of 
the  name.  In  recent  times  ether  has  again  gained  ground,  and  is  used 
especially  in  America,  in  Lyons,  and  lately  also  in  England,  in  Switzer- 
land, and  in  Germany.  In  Austria  and  in  Germany,  chloroform,  and  a 
mixture  of  chloroform,  ether,  and  alcohol,  have  the  preference.  I  use 
ether  narcosis  in  children  almost  exclusively  when  there  is  no  disease  of 
the  air-passages  and  lungs,  and  I  am  very  well  satisfied  with  it.  In 
adults  I  prefer  chloroform  narcosis,  though  neither  is  without  danger, 
as  there  have  been  fatal  cases  from  both ;  but  it  must  be  admitted  that 
fatal  cases  occur  more  frequently  from  the  use  of  chloroform  than 
of  ether.  Both  drugs,  we  shall  see,  have  their  advantages  and  dis- 
advantages, and  the  views  of  suro-eons  are  much  at  variance  as  to  which 
to  give  the  preference.  My  own  opinion  is  that  ether  should  be  used 
when  the  heart  is  diseased,  and  chloroform  is  preferable  in  cases  with 
pulmonary  lesions.  The  disadvantages  of  ether  are  its  great  inflam- 
mability and  its  volatility,  the  latter  rendering  necessary  some  special 
apparatus  for  its  administration.  Of  the  other  anaesthetics,  the  most 
useful  are  nitrous  oxide,  or  laughing  gas,  bromethyl,  and  recently 
pental,  which  is  particularly  valuable  for  short  operations,  and  is  quite 
extensively  use  by  dentists.     We  shall  first  take  up  chloroform. 

§8.  Chloroform  Narcosis.  The  Chemical  Reactions  of  Chloroform. — 
Trichlormethan  (CHCh)  is  a  clear,  colourless,  very  volatile  liquid,  with  a 
pleasant,  aromatic  odour,  and  a  sweet  and  afterwards  burning-  taste.  It  can  be 
mixed  with  ether  and  alcohol  in  all  proportions,  and  is  soluble  in  two  hun- 
dred parts  of  water.  Chloi-oform  is  very  shghtly  inflammable,  and  has  at 
15°  C.  (55°  F.)  a  specific  gravity  of  1.502.  It  is  decomposed  by  daylight  into 
hydrochloric  acid,  chlorine,  and  free  formic  acid,  and  is  therefore  to  be  kept 
in  the  dark,  preferably  in  glass  bottles  which  are  covered  with  pasteboard. 
By  the  addition  of  one  half  to  one  per  cent,  absolute  alcohol  the  decomposi- 
tion of  chloroform  can  be  prevented. 

There  are  three  different  kinds  of  chloroform  :  The  officinal  German 
chloroform,  chloral-chloroform,  and  the  English  chloroform,  the  latter  being 
purer  than  German  chloroform  and  three  times  more  expensive. 

Only  such  chloroform  should  be  used  as  has  been  previously  proved  to  be 
pure.  The  impurities  of  chloroform  consist  in  adulterations  with  spirits  of 
wine,  ether,  etc.,  in  the  very  dangerous  compounds  of  methyl  formed  during 
its  preparation,  and  finally  in  the  decomposition  products  which  develop  if 
the  drug  is  long  exposed  to  the  action  of  light  and  air  (free  chlorine,  com- 
pounds of  the  hydrocarbons  with  chlorine,  aldehyde,  hydrochloric  acid,  acetic 
acid,  and  formic  acid).  The  testing  of  chloroform  is  a  chemical  pi^ocedure, 
which  must  be  done  by  the  chemist  or  the  apothecary ;  but  the  surgeon  should 
always  make  Hepp's  smelling  test,  which  is  as  simple  as  it  is  useful.     Chem- 


§8.]  CHLOROFORM   NARCOSIS.  17 

ically  pure  Swedish  liller  paper  is  dipped  in  chloroform,  the  latter  allowed  to 
evaporate,  and  the  dry  paper  smelled  of.  If  the  chloroform  is  pure  the 
paper  has  no  odour;  but  if  there  is  a  peculiarly  sharp  and  irritating  odour 
the  chloroform  is  impure,  and  it  is  either  acid  from  decompositiou  or  it 
contains  the  chlorine  substitution  products  of  the  ethyl  or  methyl  series. 
Chloroform  can  also  be  tested  chemically  by  distillation  over  crude  pota.sh 
at  a  tcniiMM-ature  of  CO    to  CT  C.  (140°  to  142"  F.). 

Physiological  Action  ol  Chloroform.— By  inhalation,  chloroform  vapour  is 
carried  to  the  lunfrs,  or  more  particularly  to  the  blood,  and  probably  circu- 
lates in  the  blood  in  chemical  combination  with  the  haemoglobin  of  the  red 
blood-corpuscles.  Chloroform  has  the  power  in  part  of  directly  destroying 
the  red  blood-corpuscles,  and  in  part  of  robbing  them  of  their  ability  to  take 
lip  oxygen  and  to  drive  out  carbonic  acid  (Bottcher.  Schmiedeberg,  and 
others).  The  icterus — i.  e.,  haematogenous  icterus — which  Nothnagel  ol>- 
served  in  animals  is  probably  due  to  the  power  possessed  by  chloroform  and 
ether  of  destroying  the  red  blood-corpuscles. 

Hiiter  and  Witte  erroneously  ascribed  the  cause  of  the  narcosis  to  the 
change  in  the  blood,  especially  in  the  red  blood-corpuscles,  produced  by  the 
action  of  chloroform:  the  change  in  the  form  of  the  red  blood-corpuscles  to 
spheres  with  club-shaped  processes  leads,  according  to  his  theory,  to  the  for- 
mation of  coagula  in  the  cerebral  vessels,  with  a  consequent  paralysis  of  the 
nerve  centres.  But  it  is  more  probable  that  the  blood  is  only  the  means  of 
carrying  the  chloroform,  and  the  chief  cause  of  the  narcosis  is  to  be  sought 
in  the  certain  but  not  yet  wholly  understood  changes  in  the  central  nervous 
apparatus.  At  any  rate,  it  is  certain  that  these  changes  do  not  depend  upon 
disturbances  of  the  circulation,  such  as  a  hyperaemia  or  anaemia  in  the  nerve 
centres. 

The  drug  is  carried  to  all  the  organs  by  the  Vjlood  as  it  circulates,  includ- 
ing the  central  nervous  system,  the  brain,  and  the  spinal  cord.  Tlie  ganglion 
cells  are  chiefly  affected,  while  the  nerve  fibres  suffer  no  loss  of  function,  but 
retain  their  normal  excitability  (Bernstein).  The  sensory  ganglion  cells  are 
first  attacked  by  the  poison,  then  the  motor,  as  is  evident  from  the  final  pa- 
ralysis of  the  automatic  movements  of  the  heart  and  respii'ation  in  a  fatally 
ending  narcosis.  According  to  Flourens.  the  paralysis  of  the  nerve  centj-es 
begins  in  the  great  lobes  of  the  brain;  it  then  attacks  the  cerebellum,  and 
finally  the  spinal  cord,  where  fii"st  sensation  and  then  motion  are  lost.  The 
medulla  oblongata  retains  its  function  the  longest,  then  it  also  loses  its  ac- 
tivity, and  life  comes  to  an  end.  The  loss  of  sensation  and  of  the  sense  of 
pain  is  first  noticeable  in  the  back  and  extremitie?;,  and  last  in  the  cornea 
with  its  rich  nerve  supply. 

The  changes  in  the  blood  pressure  and  the  action  of  the  heart  have  been 
carefully  studied  by  Lenz,  Scheinesson.  Koch.  Bowditch.  Minot,  and  others. 
Chloroform  acts  upon  the  vaso-motor  centre,  and  also,  in  all  probability, 
directly  upon  the  heart  muscle  and  its  ganglia.  The  arterial  ten.sion  is  re- 
duced, the  blood  pressure  sinks,  the  energy  of  the  heart's  action  is  diminished, 
and  the  rapidity  of  the  circulation  is  lessened.  The  blood  of  the  whole  body 
becomes  more  or  less  venous,  and  a  decrease  in  oxidation  with  a  sinking  of 
the  temperature  of  the  body  takes  place  as  a  result  of  the  diminished  heat 
production. 
3 


18  THE  ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

Respiration  is  influenced  in  two  ways  by  fliloroforni :  in  the  first  place, 
the  direct  action  of  the  chloroform  upon  the  terminal  branches  of  the  fifth 
nerve  in  the  mucous  membrane  of  the  nose  may  cause  a  temporary  reflex 
cessation  of  breathin"-,  and  a  noticeable  slowing  of  the  heart  (stimulation  of 
the  vagus),  particularly  at  the  outset  of  the  narcosis.  '^  In  the  second  place, 
chloroform  acts  directly  upon  the  respiratory  centre,  and  the  changes  thus 
brought  about  in  respiration  are  independent  of  the  changes  in  the  circula- 
tion. The  centre  for  breathing  is  first  stimulated  by  chloroform,  and  later 
depressed,  causing  the  breathing  to  become  slower  and  more  shallow. 

The  behaviour  of  the  pupils  is  of  very  great  importance.  The  degree  of 
dilatation  depends  not  only  upon  the  amount  of  light  and  the  degree  of  ac- 
commodation, but  also  upon  the  psychical  and  sensory  impressions  from  the 
outer  world  which  are  transmitted  from  the  brain  and  cerebellum  to  the 
medulla  oblongata  and  from  this  to  the  sympathetic,  which  supplies  the 
dilator  muscles  of  the  iris.  The  dilatation  of  the  pupils  occurring  at  the  out- 
set of  the  narcosis  is  dependent  upon  the  mental  excitement  of  the  patient 
and  upon  the  reflex  stimulation  of  the  fibres  of  the  sympathetic  nerve  gov- 
erning the  opening  of  the  iris,  brought  about  by  the  irritation  of  the  branches 
of  the  trigeminal  nerve  in  the  throat.  All  these  irritations  which  dilate J^he 
pupil  cease  when  sleep  or  narcosis  takes  place,  and  the  pupil  Ls  therefore 
contracted. 

The  uterine  contractions  during  childbirth  are  not  stopped  dvu-iug  chloro- 
form nai'cosis.  The  influence  of  the  drug  upon  the  muscular  fibres  of  the 
intestine  is  not  known.  Chloroform  produces  a  complete  relaxation  of  the 
voluutai'v  muscles.  It  is  important  to  remember  that  chloroform  is  excreted 
in  the  milk  of  nursing  women,  and  may  be  found  in  the  blood  of  the  foetus. 

Chloroform  is  excreted,  according  to  Zeller,  chiefly  in  the  form  of  chlorides 
in  the  urine,  and  only  about  a  third  is  excreted  as  unchanged  chloroform  by 
the  lungs  and  kidneys.  The  excretion  of  the  chlorine  derived  from  the 
breaking  up  of  the  chloroform  in  the  system  is  just  as  slow  as  the  excretion 
of  iodine  after  the  external  application  of  iodoform. 

Unchanged  chloroform  can  be  found  in  the  urine  of  a  patient  who  has 
been  chloroformed,  and  if  the  urine  is  boiled  with  Fehling's  solution  the 
latter  will  be  immediately  reduced  to  the  black  copper  oxide,  and  not  the  red 
(Hegar-Kaltenbach,  C.  Theim.  P.  Fischer).  As  a  result  of  the  destruction  of 
the  red  blood  cells  by  the  action  of  chloroform,  hajmoglobinuria  occasionally 
occui-s,  though  bilirubinuria  is  more  common,  for  the  reason  that,  owing  to 
the  destruction  of  the  red  blood-cells,  an  increased  formation  of  bile  colom-ing 
matter  takes  place,  which  is  excreted  in  the  urine. 

§  9.  Technique  of  Chloroform  Narcosis.  The  Method  of  Administer- 
ing Cidoroform. — If  it  has  been  decided  to  narcotise  a  patient  for  an 
operation,  certain  precautionary  measures  are  to  be  observed.  His 
general  condition  must  be  determined  by  a  careful  examination  of  the 
internal  organs,  especially  the  heart  and  lungs.  In  cases  of  extensive 
pulmonary  disease,  of  pleurisy  with  effusion,  of  heart  disease,  particu- 
larly valvular  insufficiency  and  fatty  heart,  of  atheromatous  degenera- 
tion of  the  arteries,  of  alcoholism,  of  great  weakness   from    loss   of 


§9.]  TECHNIQUE  OF  CHLOROFORM   NARCOSIS.  19 

blood,  of  iineinia,  epilepsy,  and  many  diseases  of  the  bi-ain,  etc.,  one 
must  be  very  careful  in  the  use  of  anaesthetics,  and  one  must  decide  in 
each  case  whether  the  narcosis  is  justifiable.  Ether  is  to  be  preferred 
to  chloroform  for  patients  with  heart  disease,  and  in  cases  where  an 
operation  has  to  be  performed  by  gas-light. 

If  possible,  the  patient's  stomach  should  be  empty,  since  otherwise 
the  vomiting  which  so  easily  occurs  will  disturb  the  quiet  progress  of 
the  narcosis  and  of  the  operation ;  moreover,  the  movements  of  the 
diaphragm  during  the  narcosis  are  interfered  with  when  the  stomach 
is  distended.  Therefore,  without  exception,  patients  should  be  for- 
bidden to  take  solid  food  for  from  three  to  four  hours  before  the  opera- 
tion. In  England  and  America  it  is  customary  to  give  stimulants,  es- 
pecially to  weak  patients,  before  the  narcosis.  In  many  operations, 
particularly  those  in  the  peritoneal  cavity  and  about  the  region  of  the 
anus,  etc.,  the  intestine  should  be  previously  emptied  by  a  laxative  or 
enema. 

The  patient  should  be  clothed  as  lightly  as  possible,  with  no  con- 
striction in  the  region  of  the  neck,  thorax,  or  abdomen  which  interferes 
with  respiration,  and  the  thorax  should  be  uncovered  so  that  the  respira- 
tory movements  can  be  watched.  False  teeth  and  plates  must  be  re- 
moved from  the  mouth.  During  the  stage  of  excitement,  in  the  first 
part  of  the  narcosis,  I  fasten  the  patient  to  the  operating  table  by  means 
of  a  leather  strap  passed  over  the  thighs.  The  horizontal  position  is 
usually  employed,  with  the  head  slightly  raised ;  but  for  operations  on 
the  face,  in  the  mouth,  throat,  or  nose,  it  is  better  to  place  the  patient 
in  the  sitting  posture,  with  the  head  held  forward  to  prevent  the  en- 
trance of  blood  into  the  trachea,  though  some  operate  with  the  head 
hanging  back  over  the  edge  of  the  table  (Rose).  The  other  methods  in 
use  to  meet  this  difficulty  are  discussed  elsewhere  (Plugging  the  Larynx 
after  performing  Tracheotomy  ;  see  also  §  16,  Mixed  Narcosis). 

If  the  operation  must  be  performed  with  the  patient  lying  upon  his 
abdomen  or  side,  it  will  be  necessary  to  watch  the  respiration  and 
heart  action  with  great  care.  In  order  to  have  good  control  over  the 
narcosis,  and  in  case  of  accidents,  one  should  never  administer  chloro- 
form without  the  presence  of  an  assistant ;  in  case  death  should  occur 
from  chloroform,  as  well  as  for  other  reasons,  it  is  well  to  have  a  wit- 
ness present. 

When  the  narcosis  is  to  begin,  the  patient  should  be  quieted  by  a 
few  words,  and  told  to  count  slowly  and  aloud  while  inhaling  the 
chloroform  vapour,  and  thus  an  even,  quiet  breathing  is  obtained,  and 
the  gradual  effects  of  the  chloroform  can  be  observed.  Chloroform 
used  to  be  administered  by  pouring  a  few  drops  on  a  sponge  or  towel. 


20 


THE  ALLEVIATION   OP   PAIN   DURING   OPERATIONS. 


which  was  held  over  the  nose  or  moiitli  of  the  patient ;  hnt  it  is  better  to 
use  Skinner's  apparatus,  as  modified  by  Esmarch,  with  the  accompany- 
ing flask  for  sprinkling 
chloroform  in  drops 
(Fig.  15).  This  appa- 
ratus has  a  wire  frame 
which  is  covered  with 
porous  woollen  cloth 
or  thin  flannel.  Late- 
ly I  have  been  using 
the  excellent  chloro- 
form mask  which  I  saw 


Fig.  15. — Esmarch's  apparatus  for  admiuibtering  chloroform. 


used  in  Kocher's  clinic.  The  wire  frame,  which  is  easily  sterilised, 
is  made  of  two  pieces,  A  and  B  (Fig.  16),  which  fold  together  on 
a  hinge  inclosing  between  them  a  piece  of  compress  which  has  been 
previously  spread  out  on  the  frame  A.  In  administering  chloroform, 
care  must  be  taken  not  to  allow  the  patient  to  inhale  the  vapour  in  too 
concentrated  a  form,  but  to  permit  a  suitable  admixture  with  atmos- 
pheric air.  In  using  the  apparatus  illustrated  in  Figs.  16  and  17,  the 
patient  cannot  help  getting  the  vapour  suitably  diluted,  but  the  cloth 

covering  of  the 
frame  must  be 
as  porous  and 
wide-meshed  as 
possible.  Fur- 
thermore, the 
mask  should 
never  be  pressed 
down  so  tightly 
on  the  face  as 
to  prevent  tlie 
access  of  air 
from  the  sides, 
and  the  chloro- 
form should  not  be  sprinkled  on  the  apparatus  too  abundantly ;  it 
should  be  administered  in  drops,  but  continuously.  If  it  is  poured  out 
too  freely  it  not  infrequently  runs  on  to  the  neck  and  breast_of  tlie 
patient,  and  can  cause  a  very  troublesome  erythema  or  burn.  I  saw 
such  a  case  as  the  result  of  the  carelessness  of  the  chloroformer,  in 
which  there  occurred  an  extensive  and  very  painful  erythema  of  tlie 
back,  breast,  and  shoulders,  with  a  loss  of  the  epidermis  as  though  from 
a  burn.     So  it  is  best  to  lay  a  light  compress  on  the  neck  of  the  pa- 


FiG.  16.— Apparatus  for  administering  chloroform. 


^•J.J 


TECIINIQUK   OF   ClILORUFUllM   NARCOSIS. 


21 


tient,  aiul  to  place  a  piece  of  cotton  or  a  small  sponge  on  the  inner 
surface  of  the  cloth  which  covers  the  apparatus. 

Several  forms  of 
apparatus  have  hecn 
deviled  for  mixing  the 
chloroform  vapour 
with  a  kivo'wn  propor- 
tion of  air,  a  matter 
which  is  of  great  im- 
portance (Bert,  Kro- 
necker,  Pean,  Thiriur, 
Kappeler).  One  of 
the  best  of  these  is 
Junker's  (Fig.  18),  the 
description  of  which  is 

as  lOllOWS  :  Yw.  17. — Apparatus  tor  adiniuistering  chloroform. 

The  Chloroform  Ap- 
paratus of  Junker  and 
Kappeler.— The  flask  F 
is  filled  to  about  one 
third  with  chloroform, 
and  is  fastened  by  a  hook 
to  a  buttonhole  on  the 
chloroforraer's  coat.  By 
pressing'  the  rubber  bag 
B  a  mixture  of  chloro- 
form and  air  is  supplied 
to  the  patient.  The 
mouthpiece    which    the 

patient  wears  is  connected  with  the  flask  F  by  a  rubber  tube,  and  is  made 
of  hard  rubber  or  nickel-plated  metal,  with  incisures  to  fit  the  nose  and  chin, 
over  each  of  which  there  is  a  valve  to  allow  for  expiration,  and  two  other 
valves  which  can  be  closed  or  opened  to  admit  air,  thus  permitting  the  chlo- 
roform-air mixture  to  be  further  diluted.  Both  of  the  latter  valves  are  placed 
at  the  junction  of  the  mouthpiece  with  the  tube  from  the  flask  F.  Tlie  ex- 
piratory valve  is  situated  in  the  other  and  smaller  of  the  attachments  to  the 
mouthpiece.  Kajipeler  has  lately  made  an  imjn-oved  modification  of  Junker's 
chloroform  apparatus,  manufactured  by  the  optician  Falkenberg,  in  Con- 
stance. The  apparatus  of  Wiskemanu  likewise  gives  the  proper  amount  and 
proportion  of  chloroform. 

The  chief  advantage  of  Junker's  apparatus  lies  in  the  saving  of 
chloroform.  As  disadvantages,  there  are  to  be  noted  the  necessity  of 
using  both  hands  to  manage  it,  the  fatigue  from  squeezing  the  rubber 
bag,  and  the  trouble  of  filling  the  flask  with  chloroform.     I  think  evi- 


FiG.  1^.— .Junker's  apparatus  for  adiniuistering  chloroform. 


22 


THE  ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 


dence  is  lacking  to  prove  that  death  from  chloroform  is  less  liable  to 
occur  with  Junker's  apparatus  than  with  others ;  and  we  know  that  a 
considerable  number  of  deaths  from  chloroform  have  occurred  in  the 
use  of  such  contrivances  (§§  11  and  12). 

Suitable  instruments  should  be  ready,  in  case  at  any  time  during 
the  narcosis  it  may  be  necessary  to  forcibly  open  the  mouth  and  pull 
forward  the  tongue,  which  may  have  fallen  Ijack  and  plugged  the 
pharynx.  A  wedge-shaped  piece  of  wood  is  the  simplest  instrument 
for  forcibly  opening  the  mouth,  though  Ileister  and  Roser  have  devised 
special  instruments  for  this  purpose.  Heister's  is  represented  as  open 
in  Fig.  19.  By  turning  the  thumb-screw  and  separating  the  two  bars 
which  lie  in  contact;  when  the  instrument  is  closed,  the  jaws  are  forced 
apart.     Roser's  mouth-gag  is  illustrated  in  Fig.  20  as  it  appears  when 


Fig.  19. — Heister's  spec- 
ulum for  the  mouth. 


Fio.  20. — Roser's  mouth-gag. 


Fig.  21. — Forceps  for  drawing 
the  tongue  forward. 


opened.  In  Fig.  21  is  shown  an  excellent  form  of  pincers  for  seizing 
and  drawing  out  the  tongue ;  one  of  these  should  be  fastened  in  a 
buttonhole  of  the  chloroformer's  coat. 

During  the  progress  of  the  narcosis  the  condition  of  the  pulse, 
respiration,  pupils,  and  the  colour  of  the  face  must  all  be  carefully 
watched.  Any  disturbance  of  respiration  must  be  immediately  met 
by  taking  away  the  chloroform  mask,  by  drawing  forward  and  lift- 
ing the  under  jaw,  by  opening  the  mouth,  and  l)y  pulling  out  the 
tongue.  If  the  patient  vomits,  the  head  is  to  be  raised,  or,  bet- 
ter, turned  toward  one  side,  to  prevent  the  entrance  of  vomitus 
into  the  air-passages  with  a  resulting  fatal  asphyxia.  After  the 
vomiting  has  stopped,  the  mouth  should  be  wiped  out  with  a  cloth. 
The  physician  administering  the  anaesthetic  should  have  nothing 
else  to  do,  and  should  let  nothing  divert  his  attention  from  his 
duties. 


glO.]  SYMPTOMATOLOGY   OF   CIILOliOFORM   NARCOSIS.  23 

Decomposition  of  Chloroform  Vapour  by  the  Flame  of  a  Gas-light.— When 

the  va])()ur  of  chloroform  comes  in  contact  with  th(!  Ilamc  of  a  g'as-jet  there 
are  formed  tetrachloride  of  carbon,  hydrochloric-acid  gas,  and  free  chlorine 
(Bosshard),  the  latter  being-  two  gases  wliich  according  to  Stobwusser,  when 
inhaled  by  rabbits  and  guinea-pigs,  may  cause  death  from  a?dema  of  the 
lungs  and  h;«niorrhages  into  the  lung  substance.  According  to  Kunkel,  the 
liydrochloric  acid  is  the  chief  cause  of  the  discomfort  expei'ienced  in  using 
chloroform  by  candle  and  lamplight.  He  found  chlorine  only  in  small 
amounts,  which  were  probably  set  free  by  the  decomj)osition  of  hydrochloric 
acid.  To  surmount  this  difficulty,  Kunkel  recommends  abundant  ventila- 
tion, or,  if  this  is  impossible— for  instance,  during  the  progress  of  a  lapa- 
rotomy—the  use  of  a  steam  spray  of  lime-water  or  soda  or  borax  solutions,  or 
towels  soaked  in  such  a  mixture,  to  absorb  the  gas. 

Zweifel  has  observed  bronchitis  and  pneumonia  following  the  administra- 
tion of  chloroform  by  gas-light,  on  account  of  the  decomposition  of  the  chlo- 
roform ;  and  he  himself  lost  a  patient  from  catarrhal  pneumonia.  The 
fumes  are  often  so  strong  as  to  make  everybody  in  the  operating  I'oom  cough, 
and  Zweifel,  if  he  has  to  operate  by  gas-light,  uses  ether,  a  drug  which  does 
not  have  this  dj-awback. 

§10.  Symptomatology  of  Chloroform  Narcosis. — The  symptoms  of 
chloroform  narcosis  have  been  divided  into  separate  stages,  wliich, 
though  not  sharj^ly  defined  from  one  another,  are  each  very  different. 
They  are  (1)  the  stage  of  volition,  (2)  tlie  stage  of  excitement,  and  (3) 
the  stage  of  tolerance,  Kappeler  speaks  of  two  stages :  one  of  con- 
sciousness, and  the  otlier  of  unconsciousness. 

The  phenomena  of  chloroform  narcosis  consist  essentially  in  a 
change  in  the  perceptions  of  the  special  senses,  in  a  disturbance  of  the 
intelligence,Mn  a  temporary  increase  of  the  reflexes  and  tetanic  contrac- 
tion of  the  muscles,''in  changes  in  the  pupils,  in  a  gradual  loss  of  sensa- 
tion and  conscionsness,"in  changes  in  the  circulation  and  respiration, "in 
a  paralysis  of  the  voluntary  muscles,  and^  in  a  diminution  in  the  body 
temperature. 

Sometimes,  particularly  in  the  case  of  weak  and  exhausted  individ- 
uals, the  chloroform  sleep  comes  on  without  any  intermediate  stage, 
but  as  a  rule  it  is  preceded  by  a  well-marked  stage  of  excitement.  The 
patient  becomes  restless,  and  begins  to  talk,  cry  out,  shout,  sing,  laugh, 
weep,  etc.  Many  patients  fling  their  arms  and  legs  about,  try  to  get 
up,  and  act  as  though  insane.  Gradually  the  movements  of  the  artns 
and  legs  cease  ;  they  become  limp  ;  the  face,  which  has  usually  hitherto 
been  purple,  now  becomes  pale  ;  the  pupils  are  contracted,  and  no  longer 
react  to  light  or  mechanical  stimulation  ;  the  pulse  becomes  distinctly 
slower,  the  respiration  quiet,  regular,  and  at  times  rather  shallow^ ;  tlie 
patient  is  completely  insensible,  and  the  operation  can  begin. 

The  skill  of  the  chloroformer  consists  in  keeping  the  patient  in  tliis 


2i  THE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

stage  of  the  narcosis  throngliout  the  operation,  permitting  him  neither 
to  awake  nor  to  be  overcome  by  a  fatal  paralysis  of  respiration  or  of 
the  heart.  The  behaviour  of  the  pupils,  the  pulse,  and  the  respiration 
must  be  carefully  watched. 

When  the  angesthesia  is  complete,  the  pupils,  which  so  long  as  con- 
sciousness was  not  entirely  lost  began  slowly  to  dilate,  now  become  con- 
tracted. By  touching  the  cornea  their  degree  of  dilatation  will  not  be 
affected,  since  the  cornea  is  without  sensation.  Sudden  dilatation  of  the 
pupils  during  the  narcosis  is  a  dangerous  symptom,  indicating  a  threat- 
ened fa,tal  cardiac  paralysis.  At  times,  in  deep  chloroform  narcosis, 
there  occurs  an  asymmetrical  movement  of  the  eye-balls.  In  such  cases, 
while  one  eye  may  remain  looking  steadily  forward,  the  other  may  turn 
slowly  inward,  outward,  or  upward.  In  other  cases  both  eyes  may 
turn  either  in  opposite  directions  or  varying  distances  in  the  same  di- 
rection. The  occurrence  of  asymmetrical  movements  of  the  eyes  is  a 
sure  indication  of  deep  narcosis ;  the  association  of  the  ocular  move- 
ments returns  when  the  patient  awakes. 

The  heart's  action  is  increased  at  the  beginning  of  the  chlorofonn 
narcosis  and  the  pulse  Ijecomes  more  rapid ;  but  with  the  loss  of  sensi- 
bility coincident  with  contraction  of  the  pupils  and  the  paralysis  of  the 
voluntary  muscles,  the  heart's  action  becomes  weaker  and  the  frequency 
of  the  pulse  falls  below  the  normal.  Kappeler  found  that  the  fre- 
quency of  the  pulse,  a  few  hours  before  narcosis,  differed  by  from  four 
to  thirty  beats,  as  compared  with  that  during  the  narcosis. 

According  to  Kappeler,  the  pulse-curve  obtained  by  the  sphygmo- 
graph  teaches  that  the  innervation  of  the  circulatory  system  is  dimin- 
ished during  chloroform  narcosis,  the  activity  of  the  vaso-motor  nerves 
is  lessened,  and  the  arterial  blood  pressure  falls  correspondingly.  Hand 
in  hand  with  the  slowing  of  the  circulation  and  the  diminution  of  the 
blood  pressure  there  is  a  loss  of  body  temperature,  which,  according  to 
the  measurements  of  Kappeler,  amounts  to  between  0"2°  to  1*1°  C, 
or  an  average  of  0'59°  C. 

The  behaviour  of  respiration  varies  greatly  with  the  individual, 
but  both  the  frequency  aiid  the  depth  of  the  breathing  diminishes  as 
the  administration  of  the  chloroform  is  prolonged.  Chloroform  acts 
locally  upon  the  nerves  of  the  respiratory  tract,  as  well  as  on  the  re- 
spiratory centre.  In  any  stage  of  chloroform  narcosis,  particularly  in 
the  first,  there  may  be  a  cessation  of  respiration,  or  its  normal  course 
can  be  seriously  interfered  with  by  the  tongue  falling  back  against  the 
posterior  wall  of  the  pharynx.  Retching  or  vomiting  is  of  frequent 
occurrence  during  all  stages  of  chloroform  narcosis,  bvit  particularly  in 
the  first,  if  the  patient  has  had  something  to  eat  a  short  time  previously. 


t^U.J     ACCIDENTS  OCCUKRINU    DLKINU    LllLUKUFUliM   NARCOSIS.       25 

Loss  of  sensation  occurs  first  in  tlie  hack  anil  extremities,  later  in 
the  genitalia,  then  in  the  face  and  head,  and  finally  in  the  cornea,  with 
its  abundant  nerve  supply ;  and  after  the  termination  of  the  narcosis 
sensation  returns  to  these  parts  in  the  reverse  order. 

As  a  result  of  the  local  action  of  chloroform  vapour,  the  secretion  from  the 
umcous  membrane  of  the  mouth  and  nose  is  increased,  though  not  to  the 
same  extent  as  in  ether  narcosis,  and  for  the  same  reason  there  is  also  an  in- 
crease in  the  secretion  of  the  lachrymal  gland.  The  urine  sometimes  con- 
tains traces  of  albumen,  but  seldom  of  sugar. 

After  the  administration  of  chloroform  and  ether  to  animals,  Nothnagel 
almost  always  found  bile  pigment  in  the  urine.  Icterus  bas  been  observed 
in  jjatients  who  have  been  chloroformed  or  etherized,  and  bile  pigments  are 
frequently  present  in  the  urine.  After  the  internal  administration  of  chlo- 
roform, Kappeler  examined  the  urine  of  twenty-five  cases  to  determine  the 
presence  of  bile  pigments,  without  finding  a  trace  of  them. 

The  recovery  from  the  narcosis  occurs  rather  quickly,  with  a  sud- 
den dilatation  of  the  pupils.  The  patients  have  usually  lost  all  recollec- 
tion of  their  surroundings,  and  are  surprised  that  "the  operation  is  fin- 
ished. They  either  feel  perfectly  well,  or  they  complain  of  unpleasant 
sensations  in  the  head,  of  vertigo,  nausea,  and  vomiting — the  latter 
sometimes  lasting  several  days.  Many  patients  after  awakening  from 
the  narcosis  act  as  though  drunk.  Women,  in  particidar,  are  apt  to 
he  excited,  and  weep,  or  perhaps  have  serious  fits  of  hiccoughing  and 
hysterical  crying.  Many  patients,  particularly  children,  after  awaken- 
ing fall  asleep  again,  while  others  cause  anxiety  hy  remaining  asleep  for 
a  long  time. 

At  the  close  of  the  operation  the  patient  should  be  carried  as  soon 
as  possible  into  another  well-aired  room,  and  should  be  given  very  little 
to  drink  on  account  of  the  troublesome  vomiting  after  the  narcosis. 
For  the  marked  thirst,  frequent  rinsing  of  the  mouth  with  cold  water 
is  very  serviceable.  Not  infrequently  the  vomiting  is  severe  during 
the  first  twelve  to  twenty-four,  or  even  forty-eight  hours  after  the  nar- 
cosis. In  such  obstinate  cases  an  ice-bag  should  be  laid  on  the  back  of 
the  neck  and  over  the  stomach,  and  strong  black  coffee  or  iced  cham- 
pagne or  small  pieces  of  ice  may  be  given  at  intervals  by  mouth,  and 
as  a  last  resort  a  subcutaneous  injection  of  morphine  may  be  adminis- 
tered in  the  region  of  the  stomach.  Xeuber  uses  a  subcutaneous  injec- 
tion of  caffeine  two  or  three  times  a  day  (0-03  caffeine  in  a  solution  of 
l-O  caffeine  with  12-5  each  of  distilled  water  and  alcohol).  Too  much 
water  and  ice  increases  the  vomiting,  and  so  should  be  avoided. 

§  11.  Accidents  Occurring  during  Chloroform  Narcosis. — 1.  Vomiting. 
— Retchino;  or  actual  vomitino;  niav  occur  at  anv  stage  of  the  narcosis, 


26  THE   ALLEVIATION  OP  PAIN  DURING  OPERATIONS. 

but  especially  before  the  complete  loss  of  consciousness  and  towards  the 
close  of  the  narcosis.  If  the  stomach  is  full,  vomiting  regularly  takes 
place.  Occasionally  death  has  been  caused  by  asphyxia,  due  to  the  in- 
halation of  stomach  contents.  During  the  act  of  vomiting  the  patient 
usually  recovers  consciousness,  thus  causing  the  narcosis  and  the  opera- 
tion to  be  prolonged.  When  vomiting  occurs  the  head  of  the  patient 
should  be  turned  to  one  side,  and  if  the  mouth  is  tightly  closed  it  must 
be  opened  by  force  with  one  of  the  instruments  illustrated  on  page  22. 

2.  Anomalies  of  Respiration. — Irregular  respiratory  movements 
are  generally — in  fact  almost  always — to  be  expected  during  the 
narcosis. 

In  the  beginning  of  the  latter  tliere  is  not  infrequently  a  cessation- 
of  respiration  in  expiration,  generally  accompanied  by  a  spasmodic 
closure  of  the  glottis.  As  has  been  mentioned  on  page  18,  this  tem- 
porary apnoea  is  caused  reflexly  by  the  chloroform  vapour  coming  in 
contact  with  the  end  filaments  of  the  fifth  nerve  in  the  nasal  mucous 
membrane.  But  the  danger  is  greater  if  respiration  stops  during 
the  stage' of  excitement,  giving  the  characteristic  picture  of  asphyxia- 
tion :  the  thorax  is  as  stiff  as  a  board,  the  jaws  are  tightly  closed,  the 
tongue  is  drawn  back  against  the  posterior  pharyngeal  wall,  pressing 
down  the  epiglottis  and  so  closing  the  larynx,  while  the  face  becomes 
bluish  red.  Under  these  circumstances  death  can  result ;  but  such  a 
picture  should  cause  no  alarm  in  one  who  is  experienced,  as  this  dis- 
turbance in  the  respiration  can  be  easily  remedied.  After  the  stage  of 
excitement  has  passed  and  the  patient  is  fully  under  the  influence  of 
chloroform,  respiration  can  be  easily  interrupted  by  the  tongue  falling 
backward  of  its  own  weight,  pushing  down  the  epiglottis  and  thus 
closino-  the  entrance  into  the  larynx.  The  bluish-red  colouration  of  the 
face  in  such  cases  calls  attention  to  an  interruption  in  the  respiration. 

Linhart  saw  a  singular  cause  for  the  asphyxia  in  a  girl  who  had  a  very 
pointed  nose  and  extremely  thin  alae  nasi.  The  latter  were  pressed  tightly 
against  the  septum  on  both  sides  by  atmospheric  pressure  during  inspiration 
and  thus  closed  the  anterior  nares,  and  at  the  same  time  the  mouth  could 
not  be  opened  owing  to  trismus.  The  alae  were  pried  apart  with  a  penknife 
and  air  rushed  into  the  nose,  making  a  distinctly  audible  noise.  Linhart 
believes  that  the  alae  nasi  frequently  have  this  anatomical  peculiarity. 

3.  Disturbances  in  the  Circulation. — These  are  extremely  danger- 
ous, and  sometimes  occur  at  the  beginning  of  the  narcosis,  but  more 
frequently  after  the  administration  of  chloroform  has  been  kept  up 
some  time;  in  other  words,  in  the  stage  of  tolerance  or  deep  narcosis... 
Ko  matter  whether  the  respiration  is  normal  or  not,  if  the  radial  pulse 
becomes  intermittent  and  the  face  pale  there  is  need  of  the  greatest 


gl2.]     OCCURRENCE  AND  CAUSES  OF  DEATH  FROM  CHLOROFORM.      27 

care  to  prevent  the  tlircatened  syncope  from  ])roviiio:  fatal.  It  occurs 
sotnetinies  (piite  suddcnl y  and  without  warning,  and  the  ini])ending  dan- 
ger is  not  foretold  hy  irroijularity  of  the  ])ulise.  In  a  case  of  chloro- 
form syncope  the  face  turns  very  suddenly  waxy  white  and  corpselike, 
the  cornea  becomes  dull,  the  pupils  are  dilated  to  their  fullest  extent 
and  do  not  react,  the  radial  pulse  cannot  be  felt,  the  lieart  sounds  are 
very  faint  or  inaudible,  blood  ceases  to  How  from  the  divided  arteries, 
or  the  blood  that  does  flow  out  is  in  the  form  of  a  few  dark  dro])s, 
the  muscles  are  pale  and  flabby,  and  respiration  ceases.  I  liave  sev- 
eral times  experienced  the  anxiety  that  goes  with  a  threatened  death 
from  chloroform,  and  I  am  sorry  to  say  I  have  lost  two  patients  in 
this  way. 

§  12.  The  Occurrence  and  Causes  of  Death  from  Chloroform. — There 
are  no  accurate  statistics  showing  the  relation  between  the  mnnber  of 
deaths  and  the  nundjer  of  patients  to  whom  chloroform  has  been  given. 
The  number  of  published  deaths  from  this  cause  gives  no  idea  of  their 
frequency,  as  the  fatal  results  from  chloroform,  are  too  often  kept 
quiet,  and  consequently  the  statistics  on  this  point  vary  very  widely. 

Legal  Responsihility  of  the  Physician  in  Cases  of  Death  during  Nar- 
cosis.— Borntrager,  E.  Ilankel,  and  Dumont  have  made  noteworthy 
contributions  to  the  subject  of  the  legal  responsibility  of  the  physi- 
cian in  the  administration  of  chloroform  and  other  anaesthetics ;  and 
Dumont  maintains  that  the  physician  is  answerable  for  a  death  when 
he  administers  ether  to  a  patient  with  pulmonary  disease,  and  chloro- 
form to  one  with  a  cardiac  lesion.  I  should  not  consider  this  asser- 
tion of  much  legal  value,  as  a  correct  decision  can  only  be  reached  after 
consideration  of  each  case  bj  itself. 

Statistics  of  Death  from  Chloroform.— I  take  the  following  statistics  from 
Kappeler's  work  on  anaesthetics.  According  to  an  American,  Dr.  Andrews, 
there  was  one  death  in  2,723  cases  of  chloroform  narcosis.  In  eight  English 
hospitals,  between  the  years  1848-1864,  17.000  cases  were  chloroformed,  with 
one  death;  and  between  the  years  1865-1869  there  were  7,500  cases,  with  six 
deaths — a  ratio  of  1  in  1,250. 

There  is  a  very  apparent  difference  in  the  statistics  of  the  various  hospi- 
tals. In  one  hospital  a  long  interval  of  time  will  pass  with  a  great  number  of 
cases  of  chloroform  narcosis  without  a  single  death,  while  in  another,  in  the 
same  time  and  with  the  same  number  of  cases,  there  are  several  accidents. 
This  variation  in  the  proportion  of  chloroform  deaths  in  this  or  that  hos- 
pital can  be  partly  explained  by  the  greater  or  less  skill  of  the  one  intrusted 
with  the  administration  of  the  drug. 

Rendle  estimates  the  number  of  people  chloroformed  yearly,  in  the  twenty 
hospitals  in  London,  at  8,000,  with  about  three  deaths,  or  1  in  2,666. 

Bilh'otli  had   his  fii'st  fatal  case  after  giving  chloroform  12,500  times. 


28 


THE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 


Nussbaum  g'ave  it  15,000  times  wifhout  a  death.    Dr.  Coles,  in  a  report  to  the 
Medical  Society  of  Virginia,  gives  the  following  statistics: 


Anesthetic. 


Ktlier 

(  hloroforni 

Mixture  of  chloroform  and  ether 
Methylene  bichloride 


Number  of  times  used. 


92,815,  or  1 

152,260,  or  1 

11,176,  or  1 

10,000,  or  1 


23,204 

2.873 
5,588 
5,000 


To  get  a  better  knowledge  of  the  causes  of  death  from  chloroform,  Kap- 
peler  collected  the  records  of  one  hundred  and  one  cases,  seventy-eiglit  of 
which  were  men  and  twenty-two  women ;  in  one  case  the  sex  was  not  men- 
tioned. Of  these  one  hundred  and  one,  forty-three  died  before  the  full  effect 
of  the  chloroform  was  obtained,  forty-seven  in  deep  narcosis,  and  in  eleven 
the  particular  stage  of  the  narcosis  is  not  mentioned.  The  amount  of  chloro- 
form used  is  known  in  forty-six  cases,  and  it  was,  as  a  general  thing,  small, 
averaging  11 '1  grammes,  the  smallest  amount  being  twenty  drops,  and  the 
most  thirty  to  sixty  grammes.  Very  diverse  methods  of  administering  the 
chloroform  were  used,  such  as  sprinkling  it  on  simple  pieces  of  cloth,  cotton, 
or  the  regular  apparatus  of  Skinner,  Esmarch,  and  others. 

As  to  the  age  of  the  patients  who  were  opei-ated  upon  for  different  dis- 
eases, two  died  under  five  years  of  age,  twelve  between  the  ages  of  five  and 
fifteen,  nineteen  between  sixteen  and  thirty,  twenty-one  between  thirty-one 
and  forty  five,  twenty-five  between  forty  six  and  sixty.  Of  those  over  sixty 
years  of  age  one  died.     In  twenty-one  cases  the  age  is  not  given. 

Causes  of  Death  from  Chloroform.— The  causes  of  death  from  chloroform 
are  very  varied,  and  frequently  the  chloroform  is  not  to  blame  at  all.  If  a 
patient  chokes  from  aspirating  vomitus  into  the  trachea  and  bronchi,  or 
from  getting  a  set  of  false  teeth  into  his  larynx  during  the  chloroform  narco- 
sis, this  sort  of  death  is  plainly  not  due  to  the  chloi-oform.  A  certain  number 
of  sudden  deaths  take  place  even  before  the  administration  of  the  chloroform 
has  been  begun.  Desault,  for  instance,  was  about  to  perform  a  lithotomy, 
and,  to  demonstrate  to  the  spectatoi's  his  line  of  incision,  drew  his  finger- 
nail over  the  patient's  perina^um,  whereupon  the  latter  suddenly  uttered  a 
loud  cry  and  died  instantly.  Cazenave  was  going  to  perform  an  amputa- 
ti(m,  but  the  patient  was  in  such  a  state  of  nervous  depression  that  he  did 
not  venture  to  give  him  chloroform,  and  only  pretended  to  do  so  by  holding 
a  cloth,  with  nothing  on  it,  over  his  face.  Siiddenly  his  i-espiration  stopped, 
his  heart  ceased  to  beat,  and  the  patient  was  dead.  The  first  patient  to  whom 
Simpson  attempted  to  administer  chloi'oform  died  under  similar  cii-cumstances. 
The  attendant  who  was  to  bring  the  chloroform  into  the  operating  room  stum- 
bled, fell,  and  broke  the  bottle  containing  the  drug,  and  spilled  all  the  chloro- 
form on  the  floor.  The  operation,  which  was  for  hernia  (herniotomy),  had  to  be 
performed  without  chloroform,  and  at  the  first  incision  through  the  skin  the 
patient  died.  It  is  difficult  to  give  a  satisfactory  explanation  for  these  sud- 
den deaths.  Furthermore,  in  cases  wiiich  must  be  operated  upon  after  hav- 
ing lost  a  great  deal  of  blood,  if  death  occurs  from  cardiac  paralysis  during  the 
administration  of  the  chloroform,  it  is  not  to  be  put  down  to  the  anaesthetic. 


i5l2.]     OCCURRENCE  AND  CAUSES  OF  DKATH   FKoM  (  IILOROFORM.     20 

We  must  so])arate  all  those  cases  of  death  oceiirriiijr  duriiiff  the  narcosis  from 
tlie  cases  of  death  really  caused  hy  chloroform.  In  the  latter,  death  is  caused 
principally  hy  paralysis  of  the  heart  (syncope)  or  paralysis  of  respiration  (ns- 
pliyxia).  In  cases  of  death  from  syncoi)e,  the  heart's  action  ceases  hefore 
or  almost  at  the  same  time  that  respiration  does;  but  in  cases  of  death  from 
asphyxia  the  respiraticm  ceases  first  and  the  heart's  action  afterwards.  In 
any  case,  whether  the  result  of  syncope  or  asphyxia,  death  can  occur  hefore 
or  during  the  time  that  the  full  effect  of  chloroform  is  obtained,  and  there- 
fore at  the  beginninof  or  at  any  period  of  the  narcosis  proi)er. 

Of  the  twenty -three  cases  of  death  from  syncope  which  Kappelcr  collected, 
fourteen  patients  were  completely  and  nine  partially  chloroformed.  Death 
fi'om  asphyxia  occurred  ten  times  during-  complete  and  seven  times  during- 
jiartial  narcosis.  If  death  occurs  in  the  first  part  of  true  narcosis,  and  there- 
fore before  the  full  effect  of  chloroform  has  been  obtained,  the  cessation  of 
respiration  or  the  cessation  of  the  heart's  action  is  in  all  probability  depend- 
ent upon  the  trigemiuus-vagus-reflex,  as  mentioned  on  page  18.  Death  from 
asphyxia  in  the  stage  of  incomplete  narcosis  may  also  be  caused  by  spas- 
modic retraction  of  the  tongue  over  the  entrance  of  the  larynx,  or  by  spasm 
of  the  abdominal  muscles  or  of  the  dia])hragm.  Death  from  chloroform  in 
the  stage  of  deep  narcosis  is  caused  by  the  direct  paralysis  of  the  circulatory 
aiid  respiratory  centres  in  the  medulla  oblongata-  but  death  from  asjjhyxia 
during  tliis  same  stage  can  also  occur  if  the  tongue  falls  back  over  the 
entrance  into  the  larynx. 

How  far  impure  chloroform  is  responsible  for  death  in  this  or  that  case 
is  difficult  to  say ;  but  it  is  worth  remarking  that  certain  pei-sons.  even  with- 
out known  pathological  reasons,  take  chloroform  badly,  or,  in  other  words, 
show  an  idiosyncrasy  towards  it.  It  has  been  proved  by  numerous  experi- 
ments that  it  is  particularly  dangerous  to  inhale  chloroform  vapour  in  too 
concentrated  a  form,  and  Snow,  Sanson,  and  the  English  committee  which 
investigated  the  cases  of  death  from  chloroform  published  an  urgent  warning 
on  this  point.  Lallemand,  Perkin,  and  Duroy  showed  that  mammals  will 
quickly  die  if  they  are  made  to  breathe  a  mixture  consisting  of  eight  parts 
of  chloroform  to  one  hundred  of  air,  while  thej^  can  safely  breathe  a  four- 
per-cent.  mixture.  According  to  Snow,  five  parts  of  chloroform  to  ninety- 
five  parts  of  air  can  be  safely  inhaled,  but  mammals  will  die  if  the  mixture 
is  made  one  of  eight  or  ten  per  cent,  by  volume.  According  to  the  English 
Chloroform  Committee,  the  drug  should  only  be  inhaled  in  tlie  strength  of 
three  and  a  half  to  four  and  a  half  per  cent.,  and  never  in  the  form  of  con- 
centrated vapour,  the  latter  being  the  chief  cause  of  the  sudden  reflex  stoppage 
of  respiration  and  slowing  of  the  heart  from  stimulation  of  the  filaments  of 
the  trigeminal  nerve  in  the  nose  and  throat. 

Effects  of  Chloroform  and  Air  Mixture.— P.  Bert  has  recently  studied  the 
action  of  the  chloroform  and  air  mixture  upon  dogs.  Two  grammes  of 
chloroform  vapourized  in  one  hundred  litres  of  air  produced  no  noticeable 
efiPect  ;  four  grammes  of  chloroform  in  one  hundi'ed  litres  of  air  were  in- 
haled for  nine  and  a  half  hours  with  a  loss  of  4°  to  5°  body  heat  ;  six.  seven, 
and  eight  grammes  of  chloroform  in  one  hundred  litres  of  air  produced  a 
marked  loss  of  sensation  and  temperature,  and  the  animal  died  after  seven 
hours  with  a  temperature  of  30°  C.  (86°  F.J.    If  the  proportion  was  10  to  100, 


3U  TUE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

there  was  a  complete  loss  of  sensation  within  a  few  minutes,  and  the  animal 
died  after  two  to  three  houi's.  with  a  constant  diminution  of  temperatui-e.  If 
the  proportion  was  14;  to  100,  the  animal  died  in  an  hour  and  a  quarter  ;  if 
18  to  100,  in  twenty-five  minutes  ;  if  20  to  100,  he  died  immediately  and  very  sud- 
denly. Therefore,  according  to  Bert,  the  proportion  of  chloroform  to  air  for 
anaesthesia  should  be  10  to  100,  but  instant  death  will  occur  if  it  reaches  20  to  100. 
In  general,  he  recommends  that  a  strong  dose  of  chloroform  be  first  exhibited 
to  induce  sleep  quickly,  which  can  then  be  maintained  by  a  weak  mixture  of 
chloroform  and  air,  the  proper  proportion  being  ordinarily  a  mixture  of 
eight  grammes  of  chloroform  to  one  hundred  litres  of  air.  St.  Martin  con- 
sti'ucted,  for  the  purpose  of  mixing  chloroform  and  air,  a  somewhat  compli- 
cated apparatus,  made  of  two  gasometers  which  are  alternately  filled  and 
emptied.  The  air,  as  it  enters,  passes  over  a  flask  containing  a  known  amount 
of  chloroform  and  is  thus  mixed  with  the  vapour.  The  inhalation  is  con- 
ducted by  means  of  a  hard-rubber  mouthpiece  fitted  with  a  double  valve. 
Pean  has  tried  the  method  on  men  and  considers  it  useful,  the  narcosis  seem- 
ing to  progress  very  quietly.  At  all  events,  the  exi^eriments  of  Bert  show 
that  we  use  our  ancesthetics  in  much  too  large  amounts. 

Chloroform  Poisoning.— Acute  chloroform  poisoning,  which  follows  di  ink- 
ing large  amounts  of  chloroform,  has  been  observed,  particularly  in  small 
children,  but  the  children  generally  recover  with  proper  treatment— arti- 
ficial respiration,  washing  out  the  stomach,  etc. 

The  Influence  of  Pathological  Conditions  over  Death  from  Chloroform.— 
What  pathological  conditions  favour  the  occurrence  of  death  from  chloro- 
fi>rm,  and  what  does  the  post-mortem  examination  teach  on  this  subject  ? 

In  general  there  may  be  mentioned,  as  dangerous  complications  of  chloro- 
form narcosis,  fatty  degeneration  of  the  mu.sclesof  the  heart,  valvular  lesions, 
atheromatous  degeneration  of  the  walls  of  the  vessels,  particularly  of  the 
coronary  arteries,  anaemia,  chiefly  as  a  result  of  excessive  loss  of  blood, 
chronic  pulmonary  disease,  such  as  emphysema,  diseases  of  the  kidney 
(Morbus  Brightii),  and  chronic  alcoholism.  In  all  such  cases  the  narcosis 
must  be  conducted  with  the  greatest  caution.  Fatty  degeneration  of  the 
muscles  of  the  heart  is  particularly  dangerous.  Sanson  found  fatty  heart  in 
eighteen  out  of  fifty-six  cases  of  death  from  chloroform,  and  Kappeler's  sta- 
tistics show  it  sixteen  times  in  sixty  cases. 

I  do  not  underestimate  the  important  role  that  fatty  degeneration  of  the 
heart  plays  in  the  causation  of  death  fi-oni  chloroform,  as  I  can  see  that  this 
kind  of  a  heart  succumbs  quicker  to  the  action  of  chloroform  than  a  sound 
one,  but  still  I  think  that  the  influence  of  this  disease  in  causing  death  from 
chloroform  is  often  exaggerated.  We  know  that  a  slight  amount  of  fatty 
degeneration  of  the  heart  is  very  common,  and  that,  on  the  other  hand,  in 
many  well-marked  cases  the  narcosis  causes  no  trouble.  Nothnagel,  Ungar, 
Strassman,  and  Ostertag  have  shown  that  dogs  ke])t  for  hours,  during  several 
days  in  succession,  under  the  influence  of  chloroform,  die  from  extensive 
fatty  degeneration,  the  autopsy  showing  fatty  degeneration  of  the  heart, 
liver,  kidneys,  voluntary  muscles,  stomach,  and  mucous  membranes.  Drunk- 
ards, as  a  general  thing,  bear  the  narcosis  badly,  and  it  is  characteristic  for 
them  to  show  marked  disturbances  of  the  nervous  and  muscular  system, 
with  threatened  cessation  of  respii'ation,  and  with  great  tendency  to  collapse. 


^12.J  OCCURRENCE  AND  CAUSES  OF  DEATH  FROM  CULOROFORM.  31 

But  with  them  the  chronic  eiularteritis  (atheroma),  particularly  of  the 
coronary  artei-ies,  is  resjjonsiljje  for  the  occurrence  of  death.  The  severer 
forms  of  acute  or  chronic  anaMuia  increase  the  chances  of  death  from  syn- 
cope, and  it  is  well  known  that  the  activity  of  the  central  nervous  system 
depends  upon  the  amount  of  hlood  circulating  through  it,  and  the  pi'oportion 
of  oxygen  which  it  contains.  If  two  animals  of  the  same  size  are  taken  and 
the  same  amount  of  chloroform  is  given  to  each,  and  venesection  is  ])erformed 
upon  one,  the  latter  w'ill  die  before  the  former. 

The  Results  of  Autopsy  in  Cases  of  Death  from  Chloroform.— The  autopsy 
in  cases  of  death  from  chloroform  generally  i-eveals  little  that  is  character- 
istic, and  often  gives  no  satisfactory  explanation  of  the  cause  of  death.  Not 
infrequently  the  above-mentioned  pathological  changes  in  the  organs  are 
present,  and  are  more  or  less  correctly  considered  to  be  responsible  for  the 
accident.  The  blood  is  ordinarily  uncoagulated  and  dark  coloured,  but  micro- 
scopic or  chemical  examination  of  it  has  hitherto  given  no  satisfactory  ex- 
planation for  death.  It  is  worth  noting,  however,  that,  as  a  result  of  the  dis- 
turbance of  respiration,  the  blood  is  overloaded  with  carbonic  acid.  An 
observation  made  by  Recklinghausen  is  interesting  in  this  connection.  In 
three  cases  he  found  bubbles  of  gas  in  the  great  venous  trunks  and  in  the 
heart,  and  in  each  instance  death  occurred  very  quickly  after  taking  a  very 
small  amount  of  pui-e  chloroform,  the  pulse  stopping  sviddenly,  w^hile  shallow 
breathing  continued  for  a  short  time  afterwards.  It  could  not  be  determined 
what  the  bubbles  of  gas  were,  and  Sonnenberg  was  unable  to  elucidate  this 
point  by  experiments  vipon  animals.  The  experiments  only  showed  that 
nitrogen  under  certain  circumstances  is  set  free  within  the  blood-vessels. 
Before  the  above  observation  was  made,  Von  Langenbeck  and  PirogofiF  had 
also  noticed  considerable  amounts  of  gas  in  the  large  venous  trunks  and  in 
the  right  ventricle  of  the  heart  in  cases  of  death  from  chloroform.  Kap- 
peler's  more  recent  researches  have  shown  that  this  evolution  of  gas  is  not 
peculiar  to  the  death  from  chloroform,  but  is  due  to  post-mortem  changes. 
If  the  gas  is  set  free  to  any  extent  during  life,  or  if  its  presence  was  caused 
by  venesection,  death  is  produced  by  mechanical  interfei'ence  with  the  heart's 
action,  as  happened,  for  example,  in  Pirogoff's  case.  Mention  should  be 
made  of  the  fact  that  Winogradow  found  granular  degeneration  of  the  gan- 
glia of  the  heart  and  of  the  nerve  cells  of  the  brain  and  the  spinal  cord  in 
both  men  and  animals  after  death  from  chloroform. 

The  Cause  of  Death  from  Chloroform. — From  what  lias  been  said,  it 
follows  that  cliloroforui  is  a  nerve  poison  wliicli  oceasioiially  produces 
death,  particularly  if  it  is  inhaled  in  too  concentrated  a  form,  either  by 
reflex  paralysis  of  the  heart  or  respiration,  or  by  direct  paralysis  of  the 
centres  in  tlie  medulla  oblongata  governing  circulation  and  respiration. 
According  to  Winogradow^,  chloroform  causes  a  granular  degeneration 
of  the  heart  ganglia  and  the  nerve  cells  of  the  brain  and  spinal  cord. 
The  dose  of  chloroform  necessary  to  produce  death  varies  with  the  con- 
stitution of  each  case,  but  jDatliological  conditions  of  the  nervous  system, 
the  heart,  vessels,  and  the  lungs,  favour  its  occurrence.     In  general, 


32  THE   ALLEVIATION  OF   PAIN   DURING   OPERATIONS. 

death  may  result  from  reflex  jjaraljsis  of  the  lieart  or  respiration,  at 
the  beginning  of  the  narcosis,  even  from  a  small  dose,  while  fatal 
paralysis  of  the  centres  governing  circulation  and  respiration  only  oc- 
curs after  larger  doses.  Since  fatty  degenerations  of  the  liver  and  heart 
are  produced  by  prolonged  narcosis,  it  is  probable  that  these  conditions 
tend  to  cause  death  (Nothnagel,  Ungar,  and  Strassmann). 

According  to  Ostertag,  death  from  chloroform  is  chiefly  produced 
by  a  fatty  degeneration  of  the  heart  and  an  overloading  of  the  blood 
with  carbonic  acid,  as  a  result  of  the  disturbances  in  respiration  caused 
by  changes  in  the  respiratory  muscles.  According  to  R.  Evans,  the 
greater  number  of  the  deaths  depend  upon  the  overloading  of  the  blood 
with  carbonic  acid,  which  does  not  begin  in  the  lungs,  but  in  the  cap- 
illaries of  the  rest  of  the  body.  In  a  few  cases  death  from  chloroform 
can  be  caused  by  an  abundant  formation  of  gas  (nitrogen).  The  other 
causes  of  death  from  chloroform  may  be  ascribed  to  negligence.  To 
this  class  of  cases  belong  those  which  are  choked  by  vomited  matter, 
foreign  bodies  (plates  of  false  teeth),  by  the  tongue  falling  back  upon 
the  entrance  to  the  larynx,  etc. 

Amongst  the  cases  of  death  for  which  chloroform  has  been  respon- 
sible, some  might  possibly  have  been  prevented  if  more  care  had  been 
used  in  the  administration  of  the  drug  ;  but  in  many  cases  actual  patho- 
logical changes  in  the  brain,  circulatory  or  respiratory  system  really 
brought  about  the  fatal  result. 

Lastly,  it  is  certain  that  there  are  dangerous  impurities  in  chloro- 
form, notably  the  compounds  of  methyl,  which  also  occasionally  cause 
death ;  but.  unfortunately,  our  knowledge  of  this  subject  is  very  scanty. 
The  assertion  that  chloroform  produces  death  by  depriving  the  blood 
of  oxygen,  or  by  preventing  the  blood  from  taking  it  up  (Robin,  Chap- 
man, and  others),  appears  not  to  be  correct,  judging  from  Knoll's  ex- 
periments. The  form  of  death  noticed  in  a  few  cases,  which  came  on 
after  three  or  four  days  of  collapse,  is  explained  by  the  fact  that  dis- 
turbances of  metabolism  take  place  which  produce  the  fatty  degenera- 
tion of  the  viscera  previously  mentioned  (Kast,  Mester,  and  others). 

Narcosis  with  a  Mixture  of  Chloroform  and  Oxygen.— J.  Neudorfer  tries 
to  explain  the  common  accidents  and  fatal  i^esults  from  chloroform  narcosis 
in  the  following-  way  :  The  affinity  of  haemoglobin  for  oxygen  is  not  constant, 
and  varies  with  the  condition  of  health,  being  now  less,  now  greater,  accord- 
ing to  the  general  vitality  of  the  individual;  and  so,  according  to  Neudorfer, 
when  this  affinity  is  weak  the  haemoglobin's  power  of  absorbing  oxygen  is 
more  influenced  not  only  by  the  oxides  of  carbon  and  niti'ogen,  but  also  by 
other  gases  and  vapours,  by  temperature,  and  by  atmospheric  pressure,  than 
when  the  affinity  is  stronger. 

When  chloroform  is  administered  to  an  individual  whose  liEemoglobin 


§13.]  TREATMENT  OF  ACCIDENTS  DUHING  CHLOROFORM  NARCOSIS.  33 

has  a  relatively  weak  affinity  for  oxygen,  and  an  atmosphere  is  given  him  to 
breathe  which  is  cliarged  with  twenty  per  cent,  of  chloroform,  there  will  be 
twenty  volumes  of  the  latter  to  every  eighty  volumes  of  the  air  lie  get.s.  The 
blood  get:;  only  sixteen  per  cent,  of  oxygen,  instead  of  the  usual  twenty  per 
cent.,  and  so  the  hicmoglobin,  already  having  a  weakened  atlinity  for  oxygen, 
can  take  up  little  or  none,  and  the  chloroform  exercises  its  poisonous  effect 
all  the  more  easily.  Neudorfer  recommends  a  three-  to  ten-per  cent,  mixture 
of  chloroform  and  oxygen  as  the  least  dangerous  way  of  giving  the  drug. 
He  makes  the  oxygen  with  the  apparatus  of  Limousin,  by  heating  chlorate  (»f 
potash  and  peroxide  of  manganese,  and  then  stores  the  oxygen  in  a  rubber 
bag.  As  soon  as  the  latter  is  filled,  enough  chloroform  is  added  by  a  pipette 
through  a  stop-cock  to  bring  about  the  required  proportion  of  chloroform 
and  oxygen,  and  the  bag  is  shaken  to  make  the  chloroform  vapourise  quickly. 
For  inhaling  the  mixture,  Neudorfer  uses  a  mask  with  two  valves  which 
open  and  close  in  opposite  directions.     Kreutzman  ahso  likes  this  mixture. 


^  13.  Treatment  of  Common  Accidents  Occurring  during  Chloroform 
Narcosis. — We  have  seen  that  the  behaviour  of  tlie  respiration,  pulse, 
and  pupils  during  the  narcosis  should  be  watched  with  the  greatest 
care.  Death  from  chloroform  takes  place  either  from  a  primary  cessa-  •-. 
tion  of  respiration  followed  by  cessation  of  the  lieart's  action,  or  the  '  •  *' 
heart  stops  before  respiration,  or  both  respiration  and  heart  stop 
simultaneously. 

When  threatening  symptoms  appear,  it  must  be  our  aim  to  bring 
the  irregular  or  failing  respiration  and  the  weak  or  non-recognisable 
heart  action  back  to  the  normal.  In 
all  such  cases  the  administration  of 
the  chloroform  should  be  immedi- 
ately stopped. 

Overcoming  Mechanical  Interfer- 
ence with  Respiration. — The  impedi- 
ment to  respiration  may,  in  the  first 
place,  be  caused  by  the  occlusion  of 

the   opening   into   the  larvnx  by  the    Fig.  22.— The  manner  of  pushing  fonyard  the 
^  "  /•  "         1  •  lower  jaw  tor  threatened  asphyxia. 

tongue.  In  order  to  free  the  air- 
passage  in  such  a  case  we  have  three  means :  (1)  Push  forward  and 
raise  the  under  jaw  ;  (2)  draw  out  tlie  tongue ;  (3)  elevate  the_  tliorax 
and  let  the  head  and  neck  fall  back  (Howard). 
' '  To  draw  forward  and  lift  up  the  under  jaw,  seize  the  latter  behind 
the  angle  and  push  it  forward  and  upward  (Fig.  22).  By  this  procedure 
the  tongue  and  hyoid  bone  are  drawn  forward,  rendering  the  hyo-epi- 
glottic  ligament  tense,  and  this  immediately  lifts  the  epiglottis  and 
opens  the  entrance  to  the  larynx.  The  tongue  forceps  illustrated  in 
Fig.  21  is  another  means  of  effecting  the  same  result ;  or  a  loop  of 
4 


34 


THE  ALLEVIATION  OF   PAIN   DURING  OPERATIONS. 


thread  may  be  similarly  used,  or  a  pointed  hook  may  be  passed  behind 
the  middle  of  the  body  of  the  hyoid  bone  to  draw  it  forward  (Braune). 

It  is  usually  a  good  plan  to 


pass  the  forefinger  down  to 
the  epiglottis  and  by  raising 
it  open  the  larynx. 

By  Howard's  plan  of  ex- 
tendins  the  head  and  neck 
backward,  the  point  of  sup- 
port of  the  tongue,  which 
had  fallen  back  when  the 
patient  was  in  the  horizon- 
tal position,  is  changed  from 
the  posterior  wall  of  the 
pharynx  to  the  hard  palate 
or  the  boundary  between  the 
hard  and  soft  palates,  thus 
makinff  free  for  the  stream 
of  air  the  space  between  the 
root  of  the  tongue  and  the 
posterior  pharyngeal  wall. 

Artificial  Respiration. — 
If  these  measures  _  are  not 
enough  to  restore  the  inter- 
rupted breathing,  artificial 
respiration  must  be  begun 
immediately.  Every  second 
increases  the  danger  of  the 
threatened  death,  particular- 
ly if  the  pulse  is  irregular 
and  if  the  face  becomes 
deadly  pale  or  bluish.  Arti- 
ficial respiration  is  per- 
formed with  the  patient  in 
the  position  indicated  in 
Fig.  23.  The  operator 
grasps  the  lower  portion  of 
the  thorax  and  makes  vior- 


FiG.  24. — Artificial  respiration  (Silvester). 


orous  rhythmical  expiratory  movements  by  pressing  together  the  lower 
lateral  portions  of  the  thorax.  At  the  same  time  the  lower  jaw  is 
elevated  and  the  tongue  drawn  forward. 

Silvester's  method  for  performing   artificial   respiration  is  better 


§13.]  TREATMENT  OF  ACCIDENTS  DURING  CHLOROFORM  NARCOSIS.  35 

(Figs.  24,  </,  h).  Tlie  patient  is  .placed  as  quickly  as  i)OS.sible  in  the 
horizontal  position,  or  with  the  head  directed  downward  ;  the  opei-ator 
stands  behind  the  ]iatient,  and,  grasping  the  arms,  liexed  at  the  elbow, 
presses  them  laterally  against  the  chest  and  then  draws  the  arms  back- 
ward till  they  are  stretched  out  horizontally  above  the  head.  In  this 
l)rocedure  the  ribs  are  raised  by  the  traction  of  the  pectoral  muscles. 

Schiiller  has  recommended  grasping  the  arch  of  the  ribs  on  both  ' 
sides,  and,  after  vigorously  raising  them,  pressing  them  down  against 
the  thoracic  cavity.  Kraske  has  shown  that,  even  after  the  heart  has 
stopped  beating,  a  kind  of  circulation  can  be  kept  \x\)  for  a  certain 
length  of  time  by  artificial  respiration  and  by  compression  of  the  heart 
while  the  head  is  kept  lowered.  The  deep  inspiratory  movements 
aspirate  the  venous  blood  into  the  right  auricle. 

Electrical  stimulation  of  the  phrenic  nerves  is  another  method  of  u 
resuscitation  (Duchenne).  The  electrodes  of  an  induction  apparatus 
are  moistened  and  placed  on  either  side  of  the  neck,  at  the  outer  border 
of  the  sternomastoid  muscle,  which  is  pressed  somewhat  towards  the 
median  line,  and  near  the  lower  end  of  the  scalenus  anticus.  This 
stimulates  not  only  the  phrenic  nerves,  with  the  muscle  they  supply 
(the  diaphragm j,  but  also  other  nerves  and  muscles  of  inspiration  (sca- 
lenus anticus,  sternomastoid,  pectorales,  serrati,  etc.).  The  stimulation 
should  be  interrupted  about  every  two  seconds,  and  ex])iration  should 
be  aided  by  compressing  the  thoracic  and  upper  abdominal  walls. 

The  insufilation  of  air  by  means  of  a  catheter  introduced  into  the 
larynx  is  not  to  be  recommended.  If  the  larynx  is  partially  occluded 
by  a  collection  of  mucus  or  blood-clots,  or  by  a  foreign  body,  or  if 
there  is  a  spasmodic  closure  of  the  glottis,  it  may  be  necessary  to  make 
,an  opening  into  the  larynx  or  the  trachea  (laryngotomy  or  tracheotomy) 
in  order  to  perform  artificial  respiration.  But  this  necessity  seldom 
arises. 

In  desperate  cases  artificial  respiration  should  be  kept  up  from  half 
an  hour  to  an  hour,  or  even  longer.  Life  has  been  known  to  be  restored 
after  working  twenty  minutes,  even  when  any  measure  seemed  at  first 
hopeless.  There  are  successful  cases  on  record  in  which  artificial 
respiration  was  performed  for  three  to  four  hours  on  people  who  were 
apparently  drowned.  Artificial  respiration  is  also  the  best  and  surest 
wa^^  of  restoring  the  action  of  a  heart  which  is  failing  or  has  become 
imperceptible.  The  direct  mechanical  effect  of  compression  and  move- 
ment of  the  thoracic  organs  seems  to  have  a  stimulating  power  over 
the  heart's  action.  The  inversion  or  lowering  of  the  head,  accompanied 
by  artificial  respiration  (Xelaton,  Eichardson,  and  others),  appears  to 
be  particularly  advantageous  in  cases  of  syncope  from  chloroform. 


36  THE   ALLEVIATION   OP   PAIN   DURING   OPERATIONS. 

Electro-puncture  of  the  Heart. — It  has  been  recommended  to  stimulate 
the  heart  by  introducing  into  its  substance  a  needle  charged  with  an  electric 
current  (acupuncture  or  electro-puncture) ;  but  this  need  only  be  mentioned 
to  be  condemned  as  too  dangerous.  Sigmund  Mayer  has  shown  that  this 
direct  electrical  stimulation  of  the  heart  by  an  interrupted  or  constant  cur- 
rent acts  as  a  heart  poison.  Watson  experimented  on  animals,  and  found 
the  heart  could  be  punctured  without  danger,  but  if  the  vena  cava  was  en- 
tered it  was  followed  by  a  profuse  haemorrhage  into  the  thoracic  cavity. 
The  right  ventricle  was  entered  thirty-eight  times,  the  left  six  times  ;  the 
right  auricle  was  entered  six  times,  the  vena  cava  superior  three  times,  the 
vena  cava  inferior  twice,  and  the  apex  twice. 

Of  the  other  means  which  are  recommended  as  restoratives  to  be 
used  in  addition  to  artificial  respiration,  if  the  breathing  or  heart  action 
stop,  I  shall  mention  the  following :  Sprinkling  the  face  with  cold 
water ;  slapping  the  cheeks,  forehead,  or  breast  with  the  hand  or  with 
a  wet  towel ;  methodical  rubbing  of  the  extremities  so  as  to  assist  the 
peripheral  circulation  and  stimulate  the  cutaneous  nerves ;  autotrans- 
fusion  (see  page  52) ;  and  the  subcutaneous  injection  of  a  sodium  chlo- 
ride solution.  W.  Koch  reconmiends  placing  the  uncovered  pole  of 
the  induction  apparatus,  or  the  copper  wire  itself,  deep  in  the  nasal 
cavity,  and  permitting  a  strong  current  to  act  directly  on  the  nasal 
mucous  membrane  for  ten  to  twenty  seconds. 

After  a  single  or  repeated  stimulation  there  usually  occurs  a  deep 
inspiration  or  expiration,  and  breathing  proceeds  without  assistance. 
Should  the  respiration  begin  again,  and  the  pulse  become  regular,  suit- 
able stimulants  should  be  administered — olfactory  stimulants,  stimu- 
lating enemas  of  vinegar,  wine  mixed  with  water,  or  wine  alone,  sub- 
cutaneous injections  of  camphor  or  ether,  etc. 

As  a  prophylactic  measure,  particularly  in  the  case  of  very  weak, 
frightened,  or  excited  individuals,  it  is  wise  to  administer  some  alco- 
holic stimulant  before  the  operation,  such  as  Bordeaux  or  Massala 
wine,  and  Cognac  to  individuals  accustomed  to  the  use  of  alcohol.  In 
America,  particularly,  it  is  customary  to  give  to  patients  before  any 
important  operation  some  strong  alcoholic  stimulant,  such  as  brandy, 
until  the  patients  get  into  a  state  of  pleasant  excitement  or  partial 
intoxication.  It  is  believed  that  the  danger  of  cardiac  as  well  as  vaso- 
motor paralysis  during  the  chloroform  narcosis  can  thus  be  avoided. 
Moreover,  the  narcosis  under  such  conditions  comes  on  more  quickly. 

The  other  Compounds  of  Methyl.— The  other  compounds  of  methyl— 
methylether,  methylen  bichloride,  methylen ether,  and  methylal — are  now 
but  little  used  in  surgery  as  anaesthetics.  Methylen  bichloride  alone  has 
found  some  warm  adherents  in  Spencer  Wells,  Marshall,  Gamgee,  and  other 
English  surgeons.     The  drug  possesses  no  real  advantage  over  chloroform, 


§14.]  ETHER  NARCOSIS.  37 

and  only  seems  to  be  less  liable  to  cause  vomiting.  Its  disadvantages  are  its 
inflammability  and  expensiveness.  Furthermore,  its  use  is  not  free  from 
danger — in  fact  it  is  probably  more  dangerous  than  chloroform.  Kappeler 
mentions  nine  fatal  cases.  Methylen  bichloride  is  best  admiuistered  by 
Junker's  apparatus,  which  is  illustrated  on  page  21. 

§14:.  Ether  Narcosis. — Ether  is  another  much-used  ansestlietic 
which  is  coniing  to  be  employed  more  and  more  in  the  place  of  chlo- 
roform or  its  compounds.  In  America,  ether  narcosis  is  used  ahnost 
exclusively,  and  in  England,  France,  Switzerland,  and  even  Germany, 
tliis  drug  is  coming  into  constantly  growing  favour. 

Ether — sulphuric  ether,  naphtha,  ethylether,  C4H10O — is  a  colourless,  easily 
diflPusible  liquid,  possessing  a  pleasant  odour  and  burning  taste.  Ether  is  very 
volatile  and  inflammable,  and  boils  at  a  temperature  of  38°  C.  Its  specific 
gravity  at  15°  C.  is  0720.  The  physiological  action  of  ether  is  essentially 
tlie  same  as  that  of  chloroform,  except  that  ether  less  often  produces  disturb- 
ances in  the  circulatory  system,  and  consequently  seldom  causes  death  from 
syncope,  but  almost  always  from  paralysis  of  the  respiratory  centre.  P.  Bruns 
and  Holz  showed  that  the  inhalation  of  ether  produced  an  increase  in  the 
strength  of  the  pulse,  while  chloroform,  on  the  other  hand,  weakens  it. 
Kappeler  has  collected  thirteen  cases  of  death  from  ether,  but  the  number 
has  increased  lately,  owing  to  its  more  general  use.  In  diseases  of  the  air- 
passages  and  lungs  and  in  teething  children  ether  should  not  be  employed. 

The  manifestations  of  ether  narcosis  resemble  those  of  chloroform 
narcosis,  but  the  action  of  the  drug  is  not  so  lasting.  During  ether 
narcosis  the  great  amount  of  saliva  secreted  is  troublesome,  stertorous 
breathing  often  occurs,  and  not  infrequently  a  thick  white  foam  issues 
from  the  mouth  and  nose.  There  occurs,  as  a  result  of  the  dilatation 
of  the  cutaneous  vessels,  an  increased  warmth,  redness,  and  cyanosis. 
Finally,  mention  should  be  made  of  the  great  inflammability  of  this 
drug — a  circumstance  which  increases  the  difficulty  of  giving  it  at 
night  or  in  operations  where  the  galvano-  or  thermocautery  is  to  be 
used. 

Kappeler  relates  the  case  of  an  eighteen-year-old  girl,  in  Lyons, 
who  was  etherised  in  order  to  apply  the  cautery.  Suddenly,  as  the 
surgeon  was  about  to  use  the  cautery  on  his  patient,  the  ether  vapour 
ignited,  setting  fire  to  the  cone  filled  with  ether  which  was  being  held 
over  her  mouth  and  nose,  and  the  face  of  the  patient  became  enveloped 
in  flames.  Terrible  burns,  involving  the  tissues  down  to  the  bone, 
were  the  result  of  this  accident,  and  the  surgeon,  in  his  efforts  to  ex- 
tinguish the  flames,  sustained  no  inconsiderable  injuries. 

Ether  nephritis,  though  not  of  frequent  occurrence,  is  a  disagree- 
able after-effect  (Goltz).     The  other  consequences  of  ether  narcosis — 


38  THE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

the  nausea  and  vomiting — are  the  same  as  in  chloroform  narcosis. 
Sometimes  there  have  been  observed  bronchitis,  broneho-pnenmonia, 
disturbances  of  respiration  (asphyxia,  Cheyne-Stokes  breathing),  and  a 
collapsehke  condition,  especially  after  prolonged  operations.  The  cjol- 
lapse  from  ether  is  perhaps  a  result  of  the  cooling  off  of  the  surface 
of  the  body. 

Ether  narcosis  is  certainly  much  less  dangerous  than  the  narcosis 
of  chloroform,  and  cases  of  death  occur  much  less  often.  Juillard 
(Geneva),  Dumont,  P.  Bruns,  Stelzner  Fuster,  and  others,  have  recently 
substituted  ether  for  chloroform. 

On  account  of  the  great  volatility  of  ether,  it  is  advantageous  to 
use  an  apparatus  especially  designed  for  giving  it,  and  Clover's  is  the 
one  most  frequently  employed.  It  consists  of  three  closely  connected 
parts — a  metal  vessel  to  hold  the  ether,  a  rubber  bag,  and  a  mouthpiece. 
The  lower  half  of  the  metal  vessel  is  surrounded  by  a  water  tank  closed 
by  a  screw  valve,  the  tank  being  intended  to  keep  the  ether  from  cool- 
ing off  too  much.  I  use  Dumont's  modification  of  Juillard's  mask, 
consisting  of  two  metal  frames  placed  one  over  the  other  and  con- 
nected by  a  hinge,  the  outer  one  being  covered  with  oilcloth.  Between 
the  two  frames  is  placed  a  piece  of  cloth  or  flannel.  The  mask  is  large, 
and  covers  the  w-hole  face.  Over  it  is  placed  a  folded  towel  to  prevent 
the  evaporation  of  the  ether.     Czerny's  mask  is  also  very  useful. 

The  same  precautions  are  to  be  observed  in  etherising  as  in  giving 
chloroform,  and  a  pure  preparation  is  indispensable.  The  patient's 
head  should  be  so  placed  that  the  abundant  secretion  of  salivadoes  not 
flow  into  the  air-passages.  The  administration  of  the  ether  should  be 
"  pushed  "  more  than  is  customary  in  the  case  of  chloroform,  since  it 
acts  more  slowly. 

About  thirty  cubic  centimetres  of  ether  are  usually  poured  into  the 
mask  at  once.  To  keep  the  patient  free  from  pain,  the  etherisation 
demands  the  constant  attention  of  the  person  in  charge.  There  is  often 
observed  a  post-narcotic  stage  in  which  the  analgesia  continues,  though 
consciousness  has  returned.  This  also  Occurs  with  bromethyl  (see 
page  42).  Before  etherising  it  is  customary,  in  England  and  America, 
particularly  in  the  case  of  weak  individuals,  to  give  repeated  dosesjof 
brandy.  Beginning  some  two  hours  before  the  narcosis,  about  thirty 
grammes  of  brandy  are  given  every  half  hour. 

Action  of  Ether  on  the  Laryngeal  Muscles.— Somon  and  Horsley  have 
confii'Tned  by  their  experiments  the  observations  made  by  others,  namely,  that 
the  posterior  crico-arytaenoid  muscles  ,are  the  first  to  lose  their  powerj^f  con- 
fracTion  after  death,  and  in  cases  of  organic  disease  or  injury  to  the  centres 
or  to  the  bi'auches  of  the  motor  nerves  of  the  larynx. 


§15.]  LAUGHING-GAS  NARCOSIS.  ^() 

In  deep  etlier  narcosis  there  is  abduction  of  the  vocal  cords ;  and  \vhon  the 
narcosis  is  slifi'ht  there  is  adduction,  no  matter  whether  the  recurrent  laryn- 
geal  iiei'vo  is  dividrd  or  not. 

Narcosis  per  Rectum.— Moll iere  and  Iversen  liavo  successfully  ijpoduced 
ether  narcosis  by  introducing'  the  vapour  into  the  rectum  by  means  of  a 
rubber  tube  connected  with  Richardson's  ether  vapouriser.  Molliere  also 
passed  into  the  rectum  a  rubber  tube  which  was  connected  with  an  ether 
flask  stand'ng:  in  water  at  50°  C.  (112°  F.),  thus  causinj?  the  ether  to  boil. 
Molliere  mentions  as  advantages  of  rectal  ana3sthesia  the  lack  of  a  stage  of 
excitement,  the  possibility  of  exactly  regulating  the  amount  of  ether  giv^en, 
and  the  convenience  of  the  method  in  operations  on  the  face. 

Rectal  etherisation  was  first  used  by  Pirogolf  forty  years  ago.  Recently, 
Starcke  has  also  investigated  the  method  and  has  urged  its  further  trial. 

It  was  stated  on  page  38  that  fatal  cases  are  of  much  less  frequent  occur- 
rence during  ether  than  during  chloroform  narcosis.  E.  Hankel  has,  with 
the  use  of  Kappeler's  statistics,  collected  forty-five  cases  of  d^ath  from  ether 
and  analysed  the  causes  carefully ;  they  include  aspliyxia,  syncope,  general 
paralysis,  shock,  entrance  of  pus  and  ether  into  the  air-passages,  etc.  Leav- 
ing out  the  cases  of  actual  malpractice,  however,  death  from  ether  is  usually  y^.^^ 
caused  by  disturbances  of  respiration.  -'"' 

The  other  compounds  of  ethyl  have  not  become  established  as  anaesthetics; 
amongst  them  are  ethylchloride,  ethyl  bromide,  ethyluitrato,  othylidenchlo- 
ride,  ethylaldehyde  or  aldehyde,  Aran's  ether,  acetic  ether,  etc.  y 

§  15.  Laughing  Gas  Narcosis. — Amongst  the  inorganic  compounds, 
nitrogen  monoxide  or  laughing  gas  (Davy)  is  the  best  anaesthetic,  l^itrous 
oxide,  NjO,  is  a  colourless  gas  with  a  slightly  sweetish  taste  and  smell. 
It  is  made  by  cautiously  lieating  ammonium  nitrate,  wliicli  breaks  up 
at  a  temperature  of  170°  C.  into  water  and  nitrous  oxide.  The  anaes- 
tlietic  action  of  laughing  gas  is  not  unpleasant,  and  there  are  almost  no 
disagreeable  after-effects  ;  nausea  and  vomiting  scarcely  ever  occur. 
But  it  is  not  entirely  free  from  danger,  though  it  is  much  less  dangerous 
than  chloroform  or  etlier.  Statistics  show  that  out  of  four  to  five  million 
cases  where  it  has  been  used,  only  fourteen  deaths  have  been  recorded 
(E.  H.  Hankel).  In  a  few  instances  it  has  caused  epileptic  tits,  great 
excitement,  deep  cyanosis,  and  similar  phenomena,  but  in  general  the 
drug  is  relatively  free  from  danger.  After  making  investigations  with 
the  spectroscope,  Ulbrich  came  to  the  conclusion  that  nitrous  oxide 
formed  a  chemical  combination  with  the  hsemaglobin,  and  so  pould  l)e- 
come  dangerous ;  but  Preyer,  Buxton,  MacMunn,  and  Kothmann  were 
unable  to  confirm  these  statements  of  Ulbrich's,  as  the  duration  of  the 
narcosis  is  too  short,  therefore  these  authors  consider  that  nitrous  oxide 
is  not  a  dangerous  ansesthetic.  Still,  a  narcosis  of  long  duration  is  not 
to  be  recommended.  The  drug  is  suitable  for  short  operations,  partic- 
ularly the  extraction  of  teeth,  and  hence  laughing  gas  is  to-day  the  best 
anaesthetic  for  the  dentist,  and  in  England  and  America  it  is  used  with 


40  THE  ALLEVIATION  OF  PAIN  DURING  OPERATIONS. 

very  great  frequency.  In  fifty  to  sixty  seconds  the  anaesthesia  is  so 
complete  that  minor  operations,  like  the  extraction  of  teeth,  can  be  per- 
formed without  pain.  Recovery  from  the  narcosis  is  equally  prompt, 
and  without  unpleasant  after-efl'ects.  Laughing  gas  has  also  been  fre- 
([uently  used  during  parturition,  and  with  good  results  (Zweifel).  The 
gas  is  inhaled  either  pure  or  mixed  with  air.  For  the  sake  of  economy 
the  gas  is  now  stored  in  a  gasometer  or  rubber  bag  so  arranged  that 
the  expired  gas  can  be  used  over  again. 

Narcosis  with  Oxygenated  Laughing  Gas.'— Klikowitsch,  Doderlein, 
Schreiter,  and  Hillischer  have  recommended  an  oxygenated  nitrous  oxide 
(nitrous  oxide  with  twenty  per  cent,  oxygen)  for  narcosis  instead  of  the  pure 
nitrous  oxide.  It  is  suited  especially  for  protracted  narcosis  in  which  major 
surgical  operations  can  be  performed.  The  two  gases  are  stored  in  two  separate 
gasometers  and  are  mixed  immediately  before  inspiration.  The  apparatus  is 
so  arranged  that  the  proportion  of  the  mixture  can  be  altered  at  any  moment. 

Narcosis  with  Oxygenated  Laughing  Gas  and  Increased  Atmospheric  Pres- 
sure,— P.  Bert  has  recommended  the  administration  of  a  mixture  of  nitrous 
oxide  with  fifty  per  cent,  of  air  under  increased  atmospheric  pressure  (two  to 
three  atmospheres).  With  nitrous  oxide  narcosis  conducted  under  these  con- 
ditions of  increased  atmospheric  pressure,  the  operator,  his  assistants,  and  the 
patient  must  enter  a  specially  prepared  room,  where  the  air  can  be  compressed 
and  the  patient  inhale  the  nitrous  oxide.  This  atmosphere  of  compressed  air 
is  said  not  to  be  very  disagreeable  for  the  operator  and  his  assistants.  Fon- 
taine has  recently  constructed  a  pneumatic  cabinet  with  a  capacity  of  thirty 
cubic  meters,  having  large  windows  in  the  roof  and  sides,  and  fitted  with 
wheels.  Ventilation  is  supplied  by  a  valve  contrivance.  A  reservoir  with  a 
capacity  of  three  hundred  and  fifty  litres  contains  the  gaseous  mixture,  which 
is  under  a  pressure  of  two  or  more  atmospheres.  This  mixture,  as  it  is 
needed,  is  allowed  to  enter  the  sack  used  in  the  process  of  inspiration,  the 
sack  being  kept  beside  the  operating  table.  The  complexity  and  expense  of 
P.  Bert's  method  are  so  great  that  its  general  use  is  as  yet  impossible.  Labbe 
and  Pean  have  performed  a  great  number  of  prolonged  opei^ations  with  the 
use  of  nitrous  oxide  under  increased  atmospheric  pressure  and  with  excellent 
results,  and  there  is  some  talk  in  England  of  constructing  operating  rooms 
(to  accommodate  two  hundred  spectators)  according  to  P.  Bert's  directions,  for 
carrying  on  nitrous-oxide  narcosis. 

The  advantages  claimed  for  nitrous-oxide  narcosis  with  compressed  air 
are:  1.  The  absence  of  a  stage  of  excitement.  2.  The  ease  of  maintaining  for 
a  long  time  any  desired  degree  of  narcosis.  3.  The  prompt  return  of  con- 
sciousness. 4.  The  absence  of  vomiting.  5.  The  complete  freedom  from 
danger. 

Other  Anaesthetics. — The  other  inorganic  compounds  which  have  been 
tried  as  anaesthetics,  such  as  nitrogen,  carbonic  acid,  bisulphide  of  carbon, 
etc.  J  should  be  abandoned. 

§  16.  Mixed  Narcosis  and  other  Anaesthetics. — The  above-mentioned 
anaesthetics  have  been  frequently  mixed  with  each  other.     The  Vienna 


§10.j  MIXED   NARCOSIS  AND   OTHER  ANAESTHETICS.  41 

school  recommends  a  mixture  of  three  parts  ether  and  one  part  chloro- 
form. Linhart  uses  a  mixture  of  four  parts  chloroform  and  one  part 
absolute  alcohol.  Billroth  favours  a  mixture  of  three  parts  chloroform, 
one  part  ether,  and  one  part  absolute  alcohol.  The  English  Commit- 
tee on  Chloroform  has  tried  three  ditferent  mixtures :  1.  One  part 
chloroform  and  four  parts  ether,  2.  One  part  chloroform  and  two 
parts  ether.  3.  One  part  alcohol,  two  parts  chloroform,  and  three 
parts  ether. 

The  first  mixture  acts  like  unmixed  ether,  wdiile  the  other  two  are 
almost  the  same,  and,  while  inducing  a  s])eedy  loss  of  consciousness, 
interfere  less  with  the  functions  of  the  heart  than  does  pure  chloro- 
form. I  once  used  almost  exclusively  a  mixture  of  one  hundred  parts 
chloroform,  thirty  parts  ether,  and  twenty  parts  absolute  alcohol ;  but  at 
present  I  employ  pure  chloroform  or  ether,  giving  the  latter  the  prefer- 
ence for  children.  Different  authors  have  recommended  a  mixture  of 
oxygen  with  chloroform,  ether,  or  laughing  gas,  etc.  Many  surgeons 
combine  the  chloroform  and  ether  narcosis,  beginning  the  narcosis  with 
chloroform  and  keeping  it  up  with  ether.  Clover  speaks  well  of  the 
combined  use  of  nitrous  oxide  and  ether,  and  claims  in  this  way  to 
escape  the  stage  of  excitement.  Clover  uses  nitrous  oxide  first  and 
then  carries  on  the  narcosis  with  ether,  and  after  one  to  two  minutes 
the  patient  is  in  a  condition  to  be  operated  upon. 

Morphine-Chloroform  Narcosis. — The  morphine-chloroform  narcosis — 
a  combination  first  tried  by  Nussbaum — is  of  considerable  value.  It  is 
especially  suitable  for  alcoholic  cases,  and  for  individuals  in  whom  a 
well-marked  stage  of  excitement  is  to  be  expected.  One,  two,  or 
three  centigrammes  of  acetate  of  morphine  are  given  in  aqueous  solu- 
tion, hypodermically,  about  ten  to  twenty  minutes  before  the  narcosis 
is  begun,  or  immediately  preceding  the  latter ;  afterwards,  a  second  in- 
jection may  be  given  during  the  stage  of  excitement,  or  later  in  the 
progress  of  the  narcosis,  particularly  if  the  operation  is  protracted.  The 
advantages  of  a  mixed  morphine-chloroform  narcosis  (which  I  only  use 
on  adults)  are  as  follows :  The  narcosis  progresses  more  quickly  and 
quietly ;  there  is  less  mental  w^orry  ;  the  stage  of  excitement  is  short- 
ened, or  completely  absent ;  the  respiration  is  more  regular,  and  a 
smaller  amount  of  chloroform  is  required.  It  is  possible  in  this  mor- 
phine-chloroform narcosis  to  render  the  patient  insensible  to  the  pain 
of  the  operation,  while  the  reflexes  are  retained,  as  well  as  control  of 
the  voluntary  muscles,  and  the  patient  remains  in  full  possession  of 
his  senses ;  he  hears  and  answers  any  questions  which  may  be  put  to 
him.  This  state  of  narcosis  is  very  valuable  for  operations  on  the 
face,  mouth,  pharynx,  and  nose,  as  the  patient  will,  when  told  to,  eject 


42  THE   ALLEVIATION   OP   PAIN   DURING   OPERATIONS. 

the  blood  collecting  in  his  mouth,  or  swallow  it,  as  the  reflex  excita- 
bility of  the  muscles  of  the  pharynx  and  palate  is  not  lost.  If  it  is 
desired  to  obtain  this  condition  of  semi-ansesthesia,  one  and  a  half  or 
two  centigrammes  of  acetate  of  morphine  should  be  injected  about  ten 
minutes  before  the  narcosis  is  begun,  after  which  the  patient  should 
be  chloroformed  till  the  stage  of  excitement  is  reached,  and  then  the 
amount  of  chloroform  administered  should  be  gradually  diminished.    ■ 

As  objections  to  the  combined  morphine-chloroform  narcosis, 
both  Kocher  and  I  have  noticed  that  the  morphine  sleep  following  the 
operation  has  a  bad  influence  upon  breathing,  and  permits  the  inhala- 
tion of  foreign  matter  with  a  resulting  aspiration-pneumonia. 

Instead  of  injecting  morphine  subcutaneously,  two  to  four  grammes 
of  chloral  hydrate  can  be  given  hj  mouth  some  time  before  the  opera- 
tion. This  chloral-chloroform  narcosis  resembles  quite  closely  the 
morphine-chloroform  narcosis.  According  to  Kappeler,  it  is  better 
to  give  ether  combined  with  a  previous  administration  of  chloral 
hydrate  than  with  a  subcutaneous  injection  of  morphine. 

Ore,  Deneppe.  and  Van  Wetter  have  repeatedly  produced  anaesthesia  by 
injecting'  chloral  hydrate  into  a  vein,  but  this  is  entirely  too  dangerous  to  be 
made  use  of. 

Other  Anaesthetics. — Acetal. — Recently  Von  Mering  has  tested  the  anaes- 
thetic powers  of  acetal,  and  particularly  dimethyl  acetal  and  diethylacetal. 
He  strongly  recommends  a  mixture  consisting  of  two  volumes  of  dimethyl- 
acetal  and  one  volume  of  chloroform,  as  being  less  dangerous  than  chloro- 
forms since  it  has  less  of  the  paralysing  effect  on  the  heart's  action.  Liicke 
states  that  the  narcosis  induced  by  dimethylacetal  and  chloroform  has  no 
marked  stage  of  excitement,  and  only  exceptionally  causes  vomiting. 

Bromethyl. — Chisholm,  Pauschinger,  Szuman,  Sternfeld,  Scheps,  Esch- 
richt,  Gilles,  Wilcox,  and  others,  have  recommended  the  inhalation  of  brom- 
ethyl as  an  excellent  anaesthetic  for  short  operations — extraction  of  teeth,  etc. 
Wiedemann  has  used  the  drug  with  success  in  confinement  cases.  If  there 
is  tuberculosis,  or  disease  of  tlie  heai't  or  kidneys,  the  drug  is  as  dangerous  as 
chloroform.  Cases  of  death  have  been  reported  here  and  there,  which,  ac- 
cording to  Gilles,  are  principally  due  to  the  use  of  an  impure  preparation, 
and  of  too  large  a  dose,  and  to  confusing  it  with  bromethylene.  E.  Haukel 
mentions  nine  fatal  cases. 

Bromethyl  (ethyl  bromate),  bromate  of  ether,  CgHjBr,  is  a  colourless 
liquid  smelling  like  ether  and  having  a  neutral  reaction.  It  is  neither 
inflammable  nor  explosive,  but  evaporates  very  rapidly  when  exposed  to  the 
air.  When  pure  bi'omethyl  is  poured  on  the  hands  it  immediately  evapo- 
rates without  leaving  a  greasy  feeling.  If  this  is  not  the  case  the  bromethyl 
is  not  pure,  and  should  not  be  used  for  narcosis.  The  method  of  conducting 
the  narcosis  with  this  drug  is  the  same  as  with  ether  and  chloroform,  and  I 
have  used  it  with  succe.ss  in  short  operations — extraction  of  teeth,  etc. 

Bromethyl  acts  better  when  access  of  air  is  prevented  as  far  as  possible, 


gl7.]  LOCAL   AN.KSTIIESLV.  40, 

by  laying  a  piece  of  folded  clotli  or  compress  over  the  inhalation  mask,  or, 
still  better,  by  usinfr  the  JuilUird  Dinnont  ether  mask  with  its  oilcloth  covei-. 
In  children  ten  to  fifteen  fj^ranmies,  and  in  adults  ten  to  tliirty  j^rammes  are 
necessary  to  produce  the  narcosis,  which  usually  conies  on  in  about  one  half 
to  one  and  a  half  minutes  and  lasts  one  and  a  half  to  three  minutes,  and  is 
seldom  followed  by  disaj^reeable  after-efifects,  though  I  have  several  timas 
seen  vomiting.  Dui'ing  the  next  two  or  three  days  the  breath  has  an  un- 
pleasant smell  of  garlic. 

5ro?Jic//</y/c/ic  should  be  entirely  rejected.  Szutnan  observed  a  fatal  in- 
stance of  its  use  in  a  man  twenty-seven  years  old,  who  was  given  by  mis- 
take thirty  grammes  of  bromethylene  instead  of  bromethyl. 

Bromoform.— Yon  Horoch  has  studied  the  anaesthetic  eifcct  of  bromo- 
form,  but  the  results  obtained  do  not,  as  yet,  seem  to  justify  its  use  in 
su,rgery. 

Pental. — Aniylene:  which  has  been  recently  given  the  name  of  pental 
(CjHio)  by  C  A.  Kahlbaum,  has  been  much  vised  for  narcosis  in  short 
operations.  The  method  of  its  administration  is  the  same  as  that  of  chloro- 
form, and  anaesthesia  occurs  in  from  fifty  to  ninety  seconds.  It  has  no  influ- 
ence on  the  heart  and  respiration,  and  the  patient  regains  consciousness  in 
three  or  four  minutes,  while  sensation  remains  lost  for  several  minutes 
longer.  Pental  is  intlainniabie,  like  ether.  It  appears  not  to  be  fi'ee  from 
clanger,  as  Gurlt  reports  one  fatal  case,  and  Schede  and  Breuer  have  each 
observed  one  liad  case  of  syncope  and  another  of  asphyxia. 

Narcosis  resulting  from  Irritation  of  the  Laryngeal  Mucous  Membrane.— 
Brown-Sequard  made  some  very  interesting  investigations  which  show  that 
general  ana?sthesia  may  follow'  irritation  of  the  laryngeal  mucous  membrane 
with  carbonic  acid  and  chloroform,  and  he  amputated  the  thigh  of  a  rabbit 
in  this  way  without  pain.  The  irritation  of  the  laryngeal  mucous  mem- 
brane is  the  essential  thing;  ^after  division  of  the  superior  laryngeal  nerve 
anaesthesia  does  not  occur.  If  the  superior  laryngeal  nerve  on  only  one  side 
is  cut,  and  the  carbonic  acid  or  chloroform  is  then  applied,  there  results  sim- 
ply a  slight  diminution  of  sensation  on  this  side,  while  upon  the  other  there 
i"  a  condition  of  complete  or  partial  anaesthesia;  on  one  side  a  toe  could  be 
amputated  wnthout  the  least  pain,  but  on  the  other  side  the  operation  caused 
the  most  violent  manifestations  of  pain. 

§  17.  Local  Anaesthesia. — For  producing  local  anaesthesia  of  a  par- 
ticular part  of  the  body,  tlie  methods  are  :  compression,  cold,  electricity 
with  or  without  the  addition  of  a  narcotic,  and,  above  all,  the  local  ap- 
plication of  certain  drugs.  Frequently,  in  former  times,  the  vessels 
and  nerves  of  an  extremity  were  tightly  compressed  by  a  tourniquet, 
which  caused  a  local  though  certainly  insutficient  anaesthesia.  Cold  is 
also  a  good  local  antTesthetic.  James  Arnott  was  the  first  to  employ  a 
freezing  mixture  of  ice  and  salt;  but  since  1866  Kichardson's  ether 
spray  has  come  into  much  more  general  use,  and  is  far  more  convenient. 

The  ether  is  sprayed  over  some  particular  spot  on  the  skin  for  one 
or  two  minutes,  causing  tlie  skin  to  become  first  red,  then,  as  the  evap- 


44  THE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

oration  of  the  etlier  produces  cold  (—15°  C),  it  becomes  white,  parch- 
mentlike, and  without  feeling.  But  the  loss  of  sensation  is  principally 
limited  to  the  skin.  This  method  is  suitable  for  small  operations — 
opening  abscesses,  puncturing  cysts,  and  for  operations  on  the  extrem- 
ities f^fter  the  latter  have  been  tied  otf  with  a  tight  elastic  tourniquet. 
By  the  use  of  a  fan  the  anaesthesia  is  hastened,  and  by  interrupting  the 
circulation  the  freezing  of  the  tissues  is  favoured.  Robbin's  anaesthetic 
ether,  which  is  practically  methylene  bichloride,  works  better  than  the 
ordinary  sulphuric  ether.  I  am  perfectly  satisfied  with  the  anaesthesia 
produced  by  the  ether  spray,  assisted  by  Esmarch's  constriction  of 
the  extremity,  and  I  prefer  it  to  the  subcutaneous  injection  of  cocaine. 
Attempts  have  been  made  to  perform  in  this  way  even  major  opera- 
tions, such  as  ovariotomy  (Spencer  Wells),  Caesarean  section  (Richard- 
son, Greenhalgh),  joint  resections  (Szymanowski),  excision  of  the  breast, 
etc.,  but  these  instances  are  rare. 

Redard  recommends  chlorethyl  as  a  substitute  for  ether  in  the  freez- 
ing method  ;  but  it  cannot  very  well  be  used  on  an  open  wound,  as  it 
is  excessively  painful. 

A  spray  of  metliylene  bichloride  is  used  in  the  same  way  as  the 
ether  spray,  especially  in  France. 

At  present  we  have  in  cocaine  a  most  excellent  local  anaesthetic, 
which  was  first  used  in  ophthalmology  by  Roller.  The  drug  acts  espe- 
cially well  on  mucous  membranes,  and  consequently  is  very  generally 
used,  and  with  the  best  results,  in  operations  on  the  eye,  nose,  mouth, 
pharynx,  larynx,  vagina,  and  uterus.  It  is  applied  in  solution  in  the 
form  of  injections  or  instillations,  or  it  is  painted  over  the  particular 
mucous  surface  with  a  brush,  or  it  can  be  made  into  an  ointment.  The 
solution  of  cocaine  is  not  permanent,  as  it  is  very  susceptible  to  the  ac- 
tion of  fungi.  It  should  therefore  be  kept  only  in  small  quantities, 
with  a  little  bichloride  or  carbolic  added  to  it.  It  has  a  better  anaes- 
thetic action  if  the  freshly  prepared  solution  is  neutralised  by  the  addi- 
tion of  a  little  carbonate  of  sodium  (A.  Bignon).  A  five-  to  twenty-per- 
cent, aqueous  solution  is  the  best  for  operations  on  mucous  membranes. 
This  is  dropped  into  the  conjunctiva  or  painted  over  the  other  mucous 
membranes.  It  is  also  good  for  small  operations  involving  the  skin — 
incision,  removal  of  tumours,  exarticulation  of  fingers,  etc. — five,  ten, 
or  fifteen  milligrammes  being  injected  into  and  under  the  skin  with  a 
hypodermic  needle.  I  use  for  this  purpose  a  weak  solution  (one  per 
cent.),  and  inject  enough  to  fill  the  syringe  from  one  to  three  times. 
After  the  injection  one  shotild  wait  three  or  four  minutes,  as  anaesthesia 
takes  place  in  about  that  time,  and  lasts  ten,  fifteen,  or  twenty  minutes. 

By  using,  at  the  same  time,  artificial  anaemia,  or  by  a  preliminary 


i?lT.]  LOCAL   AN.ESTIIESLV.  4.- 

aj^plication  of  the  otlier  spray,  tlie  anrpstlietic  action  of  cocaine  is 
materially  assisted.  This  nietluxl  is  not  adapted  for  major  operations. 
Cocaine  is  not  free  from  danger,  and  slionld  be  administered  with  great 
care,  as  numerons  cases  of  }K)isoning  have  been  observed  dnring  its 
hypodermic  use,  though  hitherto  they  have  terminated,  as  a  rule,  fa- 
vourably. These  unpleasant  effects  are  vertigo,  excitement,  loss  of  con- 
sciousness, cramps,  pallor  of  tlie  face  accompanied  by  a  small,  rapid 
pulse,  etc.  According  to  Keclus,  there  have  been,  so  far,  fourteen  fatal 
cases  from  the  use  of  cocaine,  but  the  real  number  is  undoubtedly  much 
greater.  Death  was  generally  caused  by  injecting  too  large  an  amount 
of  a  concentrated  solution,  as  in  the  majority  of  the  cases  more  than 
twenty-two  centigrammes  of  cocaine  were  given.  Consequently  only  a 
one-  to  two-per-cent.  solution  should  be  employed  for  hypodermic  use. 
Care  must  be  used  in  dropping  it  into  the  conjunctival  sac,  especially 
in  children. 

AVolfler  uses,  as  a  maximum  dose  for  injection  about  the  liead,  two 
hundredths  of  a  gramme ;  for  the  extreniities,  five  hundredths  of  a 
grannne.  The  best  antidote  for  cocaine  poisoning  is  amyl  nitrite,  which 
should  be  given  just  as  soon  as  there  is  any  symptom  of  cerebral  anaemia 
(Feinberg), 

Cocaine  in  Conjunction  with  the  Galvanic  Current.— Wagner  and  Herzog 
have  anEesthetised  the  unbroken  skiu  with  cocaine  in  conjunction  with  the 
galvanic  current.  The  anode,  previously  dipped  in  a  cocaine  solution,  is 
placed  upon  the  skin  a  certain  distance  from  the  cathode,  and,  after  the  cur- 
rent has  been  turned  on,  the  portion  of  the  skin  lying  between  the  electrodes 
becomes  anaesthetised.  The  strength  of  the  current  was  two  to  four  miili- 
amperes.  The  method  depends  upon  the  cataphoric  action  of  the  current  in 
moving  fluids  from  the  anode  to  the  cathode. 

Cocaine  with  Ethylchloride.— E.  Nagy  has  good  results  from  the  use  of 
cocaine  in  combination  with  ethylchloride  for  the  extraction  of  teeth  (one 
third  to  one  half  a  syringeful  of  a  freshly  prepared  two-per-cent.  solution 
of  cocaine).  The  gum  is  sprayed  with  the  ethylchloride  for  about  a  minute 
after  the  injection  of  cocame,  until  a  thick  layer  of  white  crystals  forms. 

Other  Anaesthetics  possessing  a  Local  Action. — The  local  application 
of  chloroform,  opium,  saponin,  amylene,  carbon  bisulphide,  etc.,  or  the 
use  of  the  constant  or  induced  current  in  combination  with  chloroform, 
tincture  of  aconite,  the  alcoholic  extract  of  aconite,  etc.,  have  all  been 
found  to  be  of  little  value.  On  the  other  hand,  I  have  had  good  suc- 
cess with  menthol  (in  coml)ination  with  lanolin  or  olive  oil).  Menthol 
is  not  a  dangerous  drug,  and  a  whole  hypodermic  needleful  of  a  ten-  to 
twenty-per-cent.  solution  of  menthol  in  olive  oil  can  be  injected  into 
and  under  the  skin.     The  ether  spray  may  be  combined  with  it.     The 


46  THE  ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

local  application  of  a  mixture  of  equal  parts  of  menthol  and  lanolin  lias 
also  been  found  efficacious. 

As  a  substitute  for  cocaine,  Claiborne  has  recommended  stenocarpin 
in  a  two-per-cent.  solution.     It  is  a  very  expensive  alkaloid. 

ErythrophlcTeine  has  been  used  as  an  anaesthetic,  but  is  of  little  value. 
Drumin,  an  alkaloid  from  euphorbia,  has  also  been  tried.  Vidal,  Labbe, 
and  St.  Germain  have  used  chloral-methyl  for  local  anaesthesia  with 
good  results.  It  acts  not  only  upon  the  skin  but  also  upon  the  deeper 
tissues  (muscles  and  bone).  Chloral-metliyl  has  the  advantage  over  the 
ether  spray  is  that  it  can  be  used  in  operations  in  which  the  thermo- 
cautery is  employed. 


CHAPTER  III. 

THE    PREVENTION    OF    LOSS    OF    BLOOD    DURING  AN    OPERATION. ESMARCH's 

0  ARTIFICIAL    ISCII.EMIA. 

The  prevention  of  logs  of  blood  in  all  operations. — Different  methods:  Digital  com- 
pression of  the  main  artery ;  tourniquets ;  ligation,  or  "  umstechung,"  tearing,  tying- 
oflf,  or  clamping  of  adhesions  or  of  blood-vessels  before  they  are  divided. — Esmarch's 
artificial  ischsemia  in  operations  on  the  extremities:  its  technique;  its  advantages 
and  disadvantages. — Modifications  of  Esmarch's  method.— The  application  of  the 
method  to  various  parts  of  the  body. — Historical. 

§  18.  The  Prevention  of  Loss  of  Blood  during  an  Operation. — In  all 
operations  we  mi^st  bear  in  mind  the  necessity  of  making  the  loss  of 
blood  as  small  as  possible,  particnlarly  in  the  case  of  weak  or  ansemic 
individuals,  in  children  less  than  a  year  old,  and  in  the  aged.  If  this 
rule  is  not  taken  to  heart  many  a  patient  will  perish  simply  from  loss 
of  blood.     It  is  a  precious  fluid. 

The  modern  surgeon  has  many  ways  of  saving  blood  during  an 
operation.  Frequently  the  artery  supplying  the  part  in  question  is 
ligated  before  the  operation  is  begun,  as,  for  instance,  both  lingual 
arteries  in  removal  of  a  cancerous  tongue  ;  or  the  artery  is  compressed 
by  the  finger  only  while  the  operation  lasts  (digital  compression) ;  again, 
in  some  cases,  the  vessel  may  be  secured  by  a  suture  passed  through  the 
skin  and  under  the  vessel  (percutaneous  ligation  en  masse). 

In  the  extirpation  of  new  growths  and  tumours  connected  to  the  sur- 
rounding parts  by  vascular  and  more  or  less  strong  adhesions,  the  ves- 
sels, or  the  vascular  adhesions,  are  seized  by  self-locking  pincers  or 
artery  clamps,  and  the  vessels,  or  vascular  strips  of  tissue,  after  being 
secured  by  two  clamps,  or  a  double  ligature  of  silk  or  catgut,  are  divided 
between  them. 

This  procedure  is  much  facilitated  by  tearing  through  the  weak, 
non-vascular  attachments,  which  yield  readily  to  the  pressure  of  the 
finger,  while  the  stronger  and  more  vascular  parts  resist,  and  can  be  felt 
and  more  readily  recognised. 

Lacerated  wounds  bleed  less  than  incised  ones.  If  a  large  vessel  is 
wounded  the  bleeding  from  it  is  at  once  stopped  by  the  pressure  of  the 
finger,  and  the  vessel  is  then  seized  by  an  artery  clamp  and  divided  be- 

(47)' 


48  THE  PREVENTION  OF  LOSS  OP  BLOOD  DURING  AN  OPERATION. 


tween  a  double  ligature,  one  of  which  closes  the  central  and  the  other 
the  peripheral  open  end  of  the  vessel.  In  other  cases,  to  prevent  loss 
of  blood,  the  cautery  iron  or  galvano-cauterj  is  used,  etc.  The  tech- 
nique of  this  method  is  mentioned  later  (§  25). 

§  19.  Esmarch's  Artificial  Ischaemia. — The  bloodless  method  of  oper- 
ating on  the  extremities  has  been  perfected  by  the  ingenuity  of  Esmarch. 
In  removing  an  extremity  by  Esmarch's  method,  not  only  do  we  save 
the  blood  in  the  limb  to  be  amputated,  but  also,  during  the  operation, 
bleeding  is  almost  entirely  prevented  by  the  elastic  constriction  of  the 
limb  previously  made  anaemic.    The  so-called  tourniquet  (Fig.  25)  used 


Fig. 


25. — Petit'a   screw 
tourniquet. 


Fig.  Sfi. — Digital  compression 
of  the  femoral  artery. 


Fig.  27. — Disrital  compression 
of  the  brachial  artery. 


to  be  used  to  check  the  flow  of  blood  during  amputations,  or  the  same 
end  was  attained  by  compressing  the  main  artery  of  the  part  with  the 
lingers  (digital  compression).     (Figs.  26,  27.) 

Tourniquets. — The  tourniquet  illustrated  in  Fig.  25  is  the  screw  tourni- 
quet of  J.  L.  Petit  (1718).  The  encircling  baud  is  fitted  with  a  pad,  and  is 
tightened  and  held  fast  by  the  buckle  at  the  other  end  of  the  band.  By 
turning  the  screw  the  pressure  of  the  tourniquet  can  be  made  as  great  as 
desired.  The  apparatus  is  applied  in  such  a  way  that  the  pad  presses  directly 
upon  the  artery.  Besides  this  there  is  the  stick  tourniquet  (Morell),  consist- 
ing of  au  encircling  band  or  a  piece  of  cord  or  cloth,  to  fasten  around  the 
extremity,  and  a  staif  or  stick  wliich  is  passed  under  the  encircling  band. 
By  twisting  the  stick  the  constriction  of  the  limb  can  be  made  as  tight  as 
desired.  A  pad  of  cloth  or  a  roller  bandage  can  be  placed  directly  over  the 
artery. 

There  is  also  the  buckle  tourniquet  of  Assalini,  and  the  bow  tourniquet  of 
Dupuytren. 

At  the  present  time,  for  rendering  operations  on  the  extremities 
bloodless  we  use  Esmarch's  very  simple  and  efiicacious  method,  which 


§19.] 


ESMARCirS  ARTIFICIAL   ISCII.EMIA. 


49 


consists  in  tying  oiT  the  member  after  it  lias  first  heen  emptied  of 
blood.  The  old-fashioned  tourniquets  and  digital  conij)ressi(;n  have 
been  abandoned  for  this. 

Su])pose,  for  instance,  that  we  wisli  to  perform  an  amputation  of 
the  leg.  After  the  leg  has  been  properly  disinfected  and  shaved,  it  is 
first  elevated  and  then  wrapped  in  an  elastic  bandage  drawn  moderate- 
ly tight,  from  the  toes  npward  as  far  as  the  lower  third  of  the  thigh. 
The  end  of  the  bandage  is  then  held  by  an  assistant,  or  after  the  last 
turn  the  roll  is  tucked  nnder  the  immediately  preceding  turn.  The 
bandage  should  have  been  previously  disinfected  by  immersion  in  a 
solution  of  one  tenth  per  cent,  bichloride  or  of  three  to  four  per  cent, 
carbolic.  To  avoid  forcing  into  the  lymph  channels  any  noxious 
materials,  such  as  tumour  germs  or  pus,  etc.,  the  diseased  part  should 
not  be  covered  by  the  wrappings,  but  carefully  avoided  ;  or,  better  still, 
the  elastic  bandage  should  in  such  instances  not  be  used  at  all. 

Finally,  Esmarch's  rubber  tourniquet  is  wound  moderately  tight 
around  the  limb  at  the  upper  terminatioji  of  the  elastic  bandage,  and 
the  latter  is  removed.  Fig.  28  illustrates  the  usual  form  of  Esmarch's 
elastic  tourniquet,  with  a  chain  and  hook  for  fastening  it. 


Fig.  28. — Esmarch's  rubber 
tubincr  for  producing 
artificial  ischiemia. 


Fiu.  2'J.—  ClaU!}!  for  the  rubber 
tubincr  used  for  producing 
artificial  ischsemia. 


Fig.  30.— Fixation  of  Es- 
march's rubber  tubing 
by  means  of  the  clamp. 


Another  way  of  securing  the  tourniquet  is  illustrated  in  Figs.  29 
and  30.  The  two  ends  of  the  rubber  tube  are  inserted  in  a  so-called 
"  tube  clamp,"  which  consists  of  a  half-open  brass  ring  fastened  to  a 
plate.  The  ends  of  the  tube  are  well  stretched  and  forced  into  the 
slot,  and  when  relaxed  the  ends  are  held  tightly  pressed  together 
(Fig.  30).  Thus  the  extremity  is  emptied  of  blood  up  to  the  lower 
third  of  the  thigh,  and  the  leg  can  be  amputated  as  on  the  cadaver. 

At  the  conclusion  of  the  amputation  the  principal  arteries  and  veins 

are  clamped  and  tied.    This  is  quickly  done,  as  the  vessels  can  be  easily 

seen  in  the  bloodless  stump.     The  larger  muscular  branches  of  the 

arteries  will  be  found  at  the  point  where  the  connective-tissue  sheaths 

5 


50  .  THE  PREVENTION  OF  LOSS  OF  BLOOD  DURING  AN  OPERATION. 

which  envelop  tlie  different  bundles  of  muscles  cross  each  other. 
"When  all  the  visible  vessels  have  been  secured  in  the  bloodless  stump 
the  latter  is  elevated,  and  its  surface  compressed  with  two  to  three 
aseptic  sponges  or  compresses,  while  an  assistant  slowly  loosens  the 
Esmarch  tourniquet,  but  is  ever  on  the  alert  to  tighten  it  again  if  bleed- 
ing should  occur  at  any  point.  After  removal  of  the  tourniquet  the 
hitherto  apparently  dead  extremity  becomes  bright  red.  At  the  same 
time,  unless  the  stump  is  elevated  perpendicularly  and  the  wound  com- 
pressed for  a  couple  of  minutes,  there  almost  always  follows  consider- 
able oozing,  because  the  pressure  of  the  elastic  tourniquet  produces  a 
temporary  vasomotor  paralysis  which  prevents  the  smaller,  unsecured 
vessels  from  contracting  and  closing  spontaneously. 

When  Esmarch's  method  iirst  came  into  general  use  this  oozing 
was  thought  by  many  surgeons  to  be  such  a  serious  matter  as  almost  to 
outweigh  the  advantages  of  the  method,  and  others  held  that  the  loss 
of  blood  during  the  oozing  which  followed  was  greater  than  in  the 
case  of  the  old  methods.  Ice-water  irrigations,  the  application  of  the 
electric  current,  injections  of  ergot  into  the  tissues  around  the  wound, 
etc.,  were  all  practiced  to  prevent  this  oozing. 

I  have  always  been  perfectly  satisfied  with  elevating  the  stump  and 
making  pressure  on  the  wound  for  a  couple  of  minutes  with  sponges 
or  compresses,  and  after  doing  this  I  have  never  seen  any  subsequent 
oozing  worth  mentioning,  and  the  patient  loses  really  only  a  few  drops 
of  blood. 

Esmarch  recommended  that  drains  be  put  in  place,  and  the  wound 
sutured  and  dressed  antiseptically  before  removing  the  elastic  tourni- 
quet. This  can  be  done  in  suitable  cases — for  instance,  in  necrosis 
operations  or  extirpation  of  tumours.  I  never  adopt  it  in  amputations 
and  resections,  but  always  check  the  bleeding  first.  AVhichever  plan 
is  adopted,  the  extremity  which  has  been  operated  upon  should,  after 
the  dressings  have  been  applied,  be  invariably  placed  in  an  elevated 
position  for  the  next  twenty-four  hours,  as  by  this  means  the  oozing 
will  be  minimised. 

This  elevation  of  the  stump  has  also  an  antiphlogistic  and  analgesic 
effect,  and  therefore  can  be  used  with  great  advantage  in  various  forms 
of  inflammatory  processes  in  the  extremities.  "When  the  extremities 
are  elevated  there  is  regularly  a  diminution  in  the  height  of  their  tem- 
perature. According  to  Meule,  for  an  elevation  lasting  sixty  minutes, 
the  maximum  diminution  is  7-2°  C.  (12-9°  F.),  the  minimum  2°  C. 
(3.6°  F.).  Furthermore,  the  blood  pressure  is  lessened,  and  the  fre- 
quency of  the  pulse  averages  a  decrease  of  nine  beats  to  the  minute. 
Upon  this  also  depends  the  haemostatic  powei-  of  elevation. 


§19.]  ESMARCirS   ARTIFICIAL   ISCfl^EMIA.  51 

In  nianv  instances,  as  has  been  mentioned,  the  elastic  bandacre  can 
be  only  partially  applied  to  the  extremity  before  encircling  the  latter 
with  the  elastic  tourniquet ;  sometimes  the  bandage  cannot  be  used  at  all. 
The  bandage  can  be  carried  to  within  a  short  distance  of  circumscribed 
abscesses  or  very  soft  tumours,  but  if  there  is  a  spreading  suppuration  or 
phlegmonous  intiammation  tlie  Esmareh  bandage  should  not  be  used,  as 
the  infectious  matter  would  be  forced  into  the  meshes  of  the  connective 
tissue  ajid  into  the  lymph  channels.  If  it  has  been  decided  not  to  use 
tiie  Esmareh  bandage,  it  will  be  sufficient  to  hold  the  extremity  vertical 
for  a  couple  of  minutes  and  then  apjily  the  rubber  tourniquet.  The 
elevation  of  the  limb  should  be  accompanied  by  a  gentle  rubbing  of  the 
skin  from  the  periphery  towards  the  centre  to  lessen  the  amount  of 
blood  contained  in  the  limb.  Lisjer  for  years  has  practiced  vertical 
elevation  of  the  extremity  without  wrapping  it  in  Esmarch's  elastic 
bandage,  and  it  is  sufficient  for  many  cases.  At  present  I  nsually  avoid 
the  elastic  bandage,  and  use  the  elastic  tourniquet  after  elevation  of  the 
limb. 

The  advantages  of  Esmarch's  method  consist  in  the  actual  saving 
of  blood  and  in  the  possibility  of  operating  in  a  dry  wound  without 
the  need  of  sponges.  Moreover,  fewer  assistants  are  required,  and  everv- 
thing  can  be  plainly  seen — a  matter  of  much  importance  in  searching 
for  a  small  foreign  body,  like  a  needle  jjoint,  or  for  a  wound  in  a  blood- 
vessel. Furthermore,  Esmarch's  elastic  tube  tourniquet  can  be  ap- 
plied to  any  part  of  the  extremities,  which  was  not  the  case  with  the 
old-fashioned  appliances. 

The  method  has  really  no  serious  disadvantages.  It  has  been  shown 
how  easy  it  is  to  stop  the  oozing  which  follows  removal  of  the  elastic 
tourniquet  and  which  has  been  found  fault  with  by  so  many  surgeons, 
and  I  do  not  yet  consider  it  proved  that  the  edges  of  wounds,  for  in- 
stance, in  amputations,  become  more  often  necrotic  after  using  Es- 
march's method  (Konig).  Sometimes  there  has  been  observed  a  pare- 
sis of  the  nerve  trunks  of  shorter  or  longer  duration,  especially  after 
tight  constriction  of  the  arm,  and  in  exceptional  cases  cutaneous  flaps 
have  died  from  want  of  nourishment.  But  these  mishaps  are  not  to 
be  ascribed  to  the  method,  but  to  its  unskilful  application — i.  e.,  to  too 
much  compression. 

Jul.  Wolff  recommends  that  Esmarch's  procedure  be  carried  out  in  the 
following  way:  After  performing'  an  amputation,  only  the  main  vessels  are 
to  be  ligated :  then  a  temporary  antiseptic  dressing  is  applied,  the  limb  is 
raised,  and  the  elastic  tourniquet  is  removed,  after  which  one  waits  twenty 
minutes;  next  the  temporary  dressing  is  removed,  the  wound  sutured,  and  a 
permanent  antiseptic  dressing  is  applied,  but  without  exerting  great  pressure, 


52     TUE  PREVENTION  OF  LOSS  OF  BLOOD  DURL\G  AN  OPERATION. 

and  the  stump  is  placed  in  an  elevated  position.  But  I  have  found  it  much 
simpler  and  equally  etficient  to  compress  the  amputation  stump  with  aseptic 
sponges  for  about  tsvo  minutes  after  removing  the  Esmarch  elastic  tourni- 
quet. This  pressure  prevents  the  oozing  if  all  the  vessels  in  sight  have  been 
ligated  before  the  removal  of  the  tourniquet. 

The  Increased  Power  of  Absorption  possessed  by  the  Tissues  after  Removal 
of  the  Elastic  Tourniquet. — Wolfler  experimented  on  dogs  with  potassium 
ferrocyanide,  cyanide  of  potash,  strychnine,  etc.,  to  determine  whether,  in  a 
limb  rendered  anaemic  by  Esmarch's  method,  absorption  occurs  up  to  the 
point  of  application  of  the  rubber  tubing,  and  how  the  absorption  is  affected 
by  removal  of  the  constriction.  It  appeared  that  while  the  elastic  tourniquet 
remained  in  place  no  absorption  occurred,  but  that  after  it  was  removed  ab- 
sorption was  very  much  accelerated.  Therefore  Wolfler  recommends  that 
the  constriction  be  maintained  until  the  wound  has  been  dressed  antiseptic- 
ally  and  elevated.  All  moistening  of  the  wound  with  such  poisonous  sub- 
stances as  carbolic  acid,  bichloride  of  mercury,  and  the  like,  should  be  done 
before  the  removal  of  the  ela.stic  tourniquet. 

Autotransfusion. — After  great  losses  of  blood,  which  endanger  life.  Es- 
march's  bandage  may  be  applied  to  the  extremities  in  order  to  force  the  blood 
in  the  latter  towards  the  heart,  and  so  avert  a  threatened  heart  failure,  or 
cerebral  ana?mia  (so-called  autotransfusion). 

For  how  long  a  time  can  Esmarch' s  constriction  he  Jcejyt  up  vnth 
impunity  f — At  present  this  question  cannot  be  satisfactorily  answered. 
Esmarch  has  maintained  his  artificial  ansemia  on  human  limbs  for  two 
hours  and  a  quarter  without  doing  any  damage.  The  results  of  animal 
experimentation  cannot  be  applied  to  man,  and  therefore  I  shall  omit 
a  discussion  of  the  same. 

The  following  is  a  brief  summary  of  the  technique  for  applying 
Esraarch's  constriction  to  particular  parts  of  the  body.  The  method  of 
using  Esmarch's  elastic  tourniquet  on  the  shoulder  for  high  amputation 
of  the  arm,  or  for  removal  of  the  arm  at  the  shoulder  joint,  is  illustrated 
in  Fig.  31,  a  and  h.  Tlie  Esmarch  elastic  tourniquet  cannot  be  used 
for  exarticulation  of  the  arm — e.  e:..  for  a  larsre  tumour — because  here 
the  artery  would  be  compressed  against  the  head  of  the  humerus,  and 
as  soon  as  the  latter  was  freed  from  the  joint  the  tourniquet  would 
be  useless.  Therefore  it  is  better  in  such  a  case  either  to  ligate  the 
subclavian  artery  first  and  then  proceed  with  the  exarticulation,  or  to 
perform  a  high  amputation  of  the  arm,  using  Esmarch's  constricting 
rubber  tube,  then  ligate  the  vessels  in  the  stump,  and  finally  remove 
the  remaining  portion  of  the  humerus  subperiosteally.  It  is  manifestly 
not  wise  to  carry  Esmarch's  elastic  tourniquet  around  the  thorax  in  the 
form  of  a  shoulder  spica,  as  the  thorax  would  be  compressed  during 
the  narcosis.  The  manner  of  applying  the  elastic  tourniquet  in  the 
region  of  the  hip,  for  amputation  of  the  thigh,  is  illustrated  in  Fig.  32. 


§19.] 


ESMARCH'S  AIITIFICIAL   1SC1J.EMIA. 


53 


The  pressure  on  tlie  fcmorul  artery  can  be  increased  by  plaeini^  a  cloth 
pad  or  roller  bandage  benoatli  the  elastic  tube  over  the  artery.     For 


Fig.  31. 


-Esuiaroli's  tubing  applied  at  the 
shoulder. 


Fig.  3'2. — Ap])lication  of  Esmarch's  rubber 
tubiug  about  the  hip. 


amputation  of  the  hip  joint,  Esraarch  recommends  compression  of  the 
aorta  after  liaving  previously  emptied  the  intestines  (Fig.  33,  a,  h,  c). 
The  following  plan  (Volkraann's),  is  better :  after  applying  the  rubber 
bandage  tightly  np  to  the  inguinal  region,  the  elastic  tourniquet  is  carried 
from  the  femora-scrotal  commissure  in  the  direction  of  Poupart's  liga- 


FiG.  33.— Compression  of  the  aorta  (Esniarch). 

ment  ohliquelj  outward  to  the  semilunar  notcli  of  the  ilium  between  its 
two  anterior  spines.  During  the  operation  the  tube  is  held  in  the  hands 
of  an  assistant,  or,  better  still,  it  is  secured  in  position  by  three  pieces  of 
bandage  tied  around  it  and  drawn  upward  to  prevent  it  slipping  down 
after  division  of  the  muscles.     Esmarch's  artificial  ischtemia,  combined 


54  THE  PREVENTION  OF  LOSS  OF  BLOOD  DURING  AN  OPERATION. 

with  local  anaesthesia,  is  excellent  for  small  operations  on  the  fingers 
and  toes.  In  operations  on  the  male  genitals  Esmarch  winds  a  small 
rubber  tube  around  the  base  of  the  scrotum  and  penis,  and,  crossing  its 
ends  over  the  mons  veneris,  he  carries  them  around  behind  and  ties 
them  together  over  the  sacrum.  But  I  do  not  consider  the  tourniquet 
necessary,  particularly  in  amputation  of  the  penis,  where  compression 
of  the  part  with  the  fingers  is  sufiicient. 

Von  Langenbeck  has  also  used  Esmarch's  method  in  operations 
on  the  scalp.  The  head  is  first  wrapped  in  a  gauze  bandage,  according 
to  the  rules  for  applying  the  "  Mitra  Hippocratis  "  (see  §  50,  Bandag- 
ing) ;  then  the  rubber  bandage  is  passed  around  the  forehead  and  occi- 
put and  the  gauze  bandage  cut  off. 

History  of  Artificial  Anaemia.— Constriction  of  an  extremity  above  the 
point  of  ain])utation  was  much  used  Ion":  before  the  iuveution  of  the  tourni- 
quet by  Morell  and  J.  L.  Petit,  and  Ambi-oise 'Pare  practiced  the  method  in 
tlie  sixteenth  century.  Even  artificial  anaemia  is  said  to  have  been  used  here 
and  there,  though  never  so  perfectly  as  by  Esmarch.  As  Albert  points  out, 
an  English  surgeon  named  Clover,  in  1852,  before  amputating  a  thigh,  hand- 
aged  the  extremity  from  the  toes  to  the  perinteum,  and  encircled  the  limb 
with  a  tourniquet  above  the  bandage. 

Chassaignac,  in  1856,  emx)loyed  a  rubber  tube  to  constrict  an  extremity  for 
haemorrhage.  Constriction  of  an  extremity  with  a  rubber  tube  or  a  bandage, 
combined  with  elevation  of  the  extremity,  bad  been  repeatedly-  practiced  (Lis- 
ter, Silvestri,  Guyon)  before  Esmarch  brought  his  method  into  general  use. 
Grandesso  Silvestri  appears  to  have  been  the  first  to  envelop  a  limb  with  an 
elastic  bandage,  and,  instead  of  a  tourniquet,  to  have  used  an  elastic  tube. 
But  little  notice  was  taken  of  Silvestri's  proposition,  and  then  Esmarch.  with- 
out knowing  what  Silvestri  had  done,  continued  the  same  method.  The 
honour  of  bringing  artificial  ischaemia  to  its  present  perfection  is  certainly 
due  to  Esmarch. 


CHAPTER   IT. 

GENERAL    RULES    FOR    PERFORMING    AN    ASEPTIC    OPERATION    AND    FOR   THE 
AFTER-TREATMENT   OF   THE    PATIENT. 

o.  Behaviour  of  the  surgeon  during  the  operation,  b.  Experienced  assistance,  c. 
Close  observance  of  antiseptic  principles,  d.  Asepsis  and  antise])sis.  e.  Acci- 
dents during  the  operation  :  (1)  Syncope ;  (2)  spasm  ;  (3)  haemorrhage.  /.  Opera- 
tions on  "bleeders."  g.  Death  from  entrance  of  air  into  the  veins,  h.  Death 
from  other  causes,  i.  Supplement :  (1)  After-treatment  of  operative  cases ;  (2) 
the  most  important  causes  of  death  after  operation. 

§  20.  Performance  of  an  Aseptic  Operation. — After  the  above-men- 
tioned preparations  for  an  aseptic  operation  have  been  made,  and  the 
patient  has  been  anaesthetised,  every  operation  should  be  performed 
qnickly,  without  hesitation,  and  with  the  most  scrupulous  regard  to 
antiseptic  precautions.  It  is  not  of  so  much  importance  now  as  it  was 
before  the  introduction  of  anaesthesia  to  perform  an  operation  with 
great  rapidity  in  order  to  spare  the  patient  pain.  But  even  at  the 
present  time  we  perform  operations  as  quickly  as  possible,  because  we 
know  that  an  operation  by  lasting  for  too  long  a  time  may  prove  fatal 
to  the  patient.  Especially  is  this  true  in  operations  in  the  peritoneal 
cavity,  which  may  prove  fatal  shortly  after  the  operation  because  of 
the  long-continued  loss  of  body  heat  (Wegner).  The  most  important 
conditions  for  rapid  and  safe  operating  are :  a  careful  examination  of 
the  patient  before  operation  ;  a  certain  diagnosis ;  accurate  anatomical 
knowledge  ;  and  a  natural  manual  dexterity.  A  sharp  knife  and  proper 
instruments  scrupulously  clean  are,  of  course,  indispensable. 

As  we  are  fully  conversant  of  the  fact  that  all  wound  diseases  are 
the  result  of  infection  by  bacteria,  and  that  the  life  of  our  patient  may 
be  placed  in  great  danger  if  the  bacteria  enter  the  wound,  we  must 
always  observe  the  strictest  asepsis ;  no  unclean  linger,  no  instrument 
which  has  not  been  previously  disinfected,  must  come  in  contact  with 
the  wound.  The  hands  and  clothing  of  the  operator  and  his  assist- 
ants, the  instruments,  sponges,  or  gauze  pads,  the  field  of  operation, 
etc.,  are  sterilised  after  the  method  described  in  §  6,  and  everything 
around  the  area  to  be  operated  upon  is  covered  with  aseptic  compresses 

(55) 


56     GENERAL  RULES  FOR  PERFORMING  AN  ASEPTIC  OPERATION. 

or  towels.  Beside  the  operator  and  his  assistants  there  should  be 
suitable  basins  for  holding  clean  disinfecting  solutions,  especially  three- 
per-cent.  carbolic  or  1  to  1,000-5,000  bichloride.  Particular  care 
must  be  taken  that  the  wound  is  not  contaminated  directly  or  indi- 
rectly by  any  spectatoi-'s  hands  which  have  not  been  disinfected — for 
instance,  by  allowing  him  to  pass  instruments,  sponges,  etc.  Most 
carefully  sterilised  sponges  or  pads  are  used  to  keep  the  wound  dry, 
but  they  should  bring  nothing  into  the  wound  from  the  surface  sur- 
rounding it.  For  operating  upon  the  cavities  in  the  body — e.  g.,  the 
mouth,  vagina,  etc. — "  clamp  sponges  "  are  required. 

An  excellent  pad  or  sponge  holder  is  ilhistrated  in  Fig.  34.  By 
pushing  up  the  ring  the  jaws  are  closed,  and  so  firmly  hold  the  sponge 
or  pad.  The  use  of  too  concentrated  antiseptic  solutions 
should  be  avoided,  for  they  may  cause  dangerous  or  even 
fatal  poisoning.  We  should  make  it  our  aim  to  irritate 
the  wound  as  little  as  possible. 

The  beginner  must  learn  gradually,  by  experience,  all 
that  I  have  mentioned ;  what  he  can  learn  from  books  is 
not  sufficient.  When  the  operation  is  finished,  the  fate 
of  the  patient  is  practically  already  settled. 

Lister's  original  antiseptic  spray  of  three-per-cent.  car- 
bolic acid,  etc.,  is  at  present  seldom  used  during  operations  ; 
and  the  once  popular  antiseptic  irrigation  has  been  pretty 
generally  abandoned,  and  rightly,  as  it  is  unnecessary  in  a 
fresh,  uninfected  operation  wound  made  by  perfectly  dis- 
infected instruments  and  aseptic  hands. 

§  21.  The  Accidents  during  an  Operation. — The  accidents 
which  are  liable  to  occur  during  an  operation  can  be  only 
briefly  mentioned  here.  We  naturally  leave  out  of  account 
Sponc^e" holder  ^^^  ^^^^  uumerous  Unpleasant  things  which  may  be  caused 
by  the  operator's  error  in  diagnosis,  his  lack  of  skill  and 
judgment,  etc.  The  reader  is  referred  to  my  text-book  on  special 
surgery  for  many  common  accidents  peculiar  to  certain  operations — 
such  as  the  disturbances  which  may  be  caused  by  operations  on  the 
mouth,  air  passages,  and  thoracic  and  peritoneal  cavities. 

Mention  has  been  made  on  pages  33  and  34  of  the  accidents  occur- 
ring daring  narcosis.  I  will  describe  the  other  unfortunate  occurrences 
briefly  as  follows : 

Syncope. — Syncope  occasionally  takes  place,  especially  in  weak  and 
anaemic  individuals,  during  small  operations  performed  without  chloro- 
form. It  either  comes  on  suddenly,  without  warning,  or  it  is  preceded 
by  a  feeling  of  anxiety,  or  a  sinking  feeling  about  the  pit  of  the  stom- 


^21.J  THE   ACCIDENTS   DURING   AN   OPERATION.  57 

ach,  or  nausea,  etc.  Tlie  face  becomes  deadly  pale  and  covered  with  a 
cold  sweat,  consciousness  is  lost,  and  the  patient  falls  to  the  floor  if 
standing,  or  drops  to  one  side  if  he  is  sitting  in  a  chair.  Sudden  death 
has  been  known  to  occur  in  this  way,  as  mentioned  on  page  28.  Dur- 
ing the  swoon  the  sense  of  pain  is  lost. 

Cramj)s. — Hysterical  or  alcoholic  individuals  sometimes  have  con- 
vulsions either  with  or  without  the  syncope.  If  the  cause  of  the  syn- 
cope is  purely  nervous  the  patient  soon  recovers,  usually  after  a  few 
seconds,  and  seldom  requires  longer  than  two  or  three  minutes.  If 
excessive  loss  of  blood  is  the  cause  of  the  syncope  the  prognosis  is  of 
course  less  favourable.  The  nature  and  treatment  of  this  form  of  syn- 
cope will  be  taken  up  under  the  subject  of  Wounds. 

The  treatment  of  the  nervous  syncope,  if  I  may  call  it  such,  con- 
sists in  placing  the  patient  in  the  horizontal  position,  sjirinkling  the 
face  with  cold  water,  dialing  and  rubbing  the  body  and  soles  of  the 
feet  with  wet  cloths,  giving  stimulants,  camphor,  wine,  ammonia,  also 
plenty  of  fresh  air,  etc. 

Bleeding. — The  dangers  which  arise  from  bleeding  during  an 
operation  are  slight,  as  the  capable  and  careful  surgeon  is  able  to  con- 
trol it  in  a  great  many  ways.  The  treatment  of  bleeding  is  discussed 
in  §§  27-30. 

An  operation  may  be  complicated  in  a  very  dangerous  way — if  it 
is  undertaken  on  an  individual  of  the  class  of  so-called  "  bleeders." 

The  "Bleeder  Disease,"  or  Hsemophilia.— The  term  ''bleeder  disease,"  or 
haemophilia,  is  understood  to  mean  a  constitutional  anomaly,  almost  always 
congenital,  which  is  characterised  by  a  very  marked  predisposition  to  bleed- 
ing spontaneously  or  as  the  i*esult  of  some  slight  traumatism. 

Haemophilia  is  generally  an  inherited  disease,  and  occurs  in  so-called 
bleeder  families,  in  which  it  is  transmitted  through  many  generations,  afilict- 
ing  the  members  in  both  the  direct  and  indirect  lines  of  descent.  Lassen 
has  investigated  three  generations  of  a  bleeder  family  of  one  hundred  mem- 
bers which  took  its  origin  from  healthy  parents;  seventeen  of  this  family 
were  bleeders,  and  nine  died  from  excessive  loss  of  blood.  The  disease 
appears  to  be  more  common  in  the  male  sex — according  to  Konig,  in  the  pro- 
portion of  one  woman  to  thirteen  men.  Furthermore,  it  is  a  fact  that  haem- 
ophilia is  transmitted  chiefly  through  the  female  members  of  the  bleeder 
family  who  do  not  themselves  suffer  from  the  disease  and  who  marry  healthy 
men.  Moreover,  the  children  of  a  male  hsemophiliac  are  usually  free  from 
the  disease.  In  only  exceptional  cases  this  anomaly  appeal's  not  to  be  con- 
genital but  to  develop  slowly  after  birth; 

The  pathology  of  hasmophilia  is  still  but  little  understood.  The  cause  of 
the  disease  has  been  ascribed  to  an  abnormal  thinness  of  the  w^alls  of  the 
vessels,  leading  to  their  easy  rupture;  to  their  possessing  too  slight  a  power 
of  contraction,  or  rather  to  a  deficiency  in  the  muscular  coat  of  the  arteries; 


58      GENERAL  RULES  FOR  PERFORMING   AN  ASEPTIC  OPERATION. 

to  an  abnormal  blood  pressure  due  to  too  small  a  calibre  in  the  main  arterial 
trunks;  and,  finally,  to  an  abnormality  in  the  composition  of  the  blood,  mani- 
fested by  imperfect  coagulation.  But  there  is  no  proof  that  any  of  ihece 
causes  actually  produce  haemophilia,  and  the  microscopical  and  clieraical 
examination  of  the  blood  has  hitherto  warranted  no  conclusion  as  to  the  eti- 
ology of  the  disease.  The  blood  usually  coagulates  normally,  though  I  can 
affirm,  in  respect  to  one  case  at  least,  that  the  blood  coagulated  rather  slow- 
ly and  imperfectly.  The  patient  died  from  the  constantly  recurring  loss  of 
blood  from  a  wound  of  the  forearm.  I  regret  that  I  did  not  make  a  careful 
examination  of  the  blood  in  this  case,  but  I  believe  that  the  blood,  or  rather 
its  power  of  coagulation,  is  not  normal  in  haemophilia. 

We  know  that  in  pronounced  leucaemia,  a  disease  of  the  blood  character- 
ised by  the  presence  of  an  excess  of  white  blood-corpuscles,  severe  or  unre- 
strainable  haemorrhage  may  occur.  For  this  reason  surgeons  hesitate  be- 
fore removing  an  enlarged  spleen  in  leucajinia;  almost  all  the  patients 
hitherto  operated  upon  have  died  from  hasmorrhage.  The  walls  of  the  blood- 
vessels in  a  case  of  haemophilia  probably  do  not  possess  the  normal  degree  of 
strength,  and  consequently  are  easily  ruptured  by  the  slightest  traumatism, 
or  even  without  any  known  cause. 

Thiersch  also  thinks  that  tlic  cause  of  haemophilia  lies  in  an  analomous 
condition  of  the  walls  of  the  blood-vessels  and  in  the  way  the  new  vessels 
are  formed  in  the  healing  of  the  wound.  Thiersch  correctly  emphasises  the 
fact  that  the  haenioi'rhage  always  begins  anew  when  the  scab-©r  thrombus  is 
disturbed,  and  thei^efore  he  believes  that  each  time  the  scab  or  thrombus 
comes  away  the  newly-formed  vessels  have  not  sufficiently  strong  walls  to 
withstand  the  pressure  of  the  blood;  the  cells  or  the  intercellular  cement 
substance,  or  both,  are  usually  at  fault. 

As  to  the  symptomatology  of  haemophilia,  the  haemorrhages  sometimes 
begin  immediately  after  birth — for  instance,  as  an  umbilical  haemorrhage— or 
they  accompany  circumcision  in  Jewish  boys,  but  usually  they  make  their 
appearance  later,  at  the  time  of  dentition,  of  shedding  the  milk  teeth,  or  at 
the  age  of  puberty;  in  other  words,  at  periods  of  life  when  traumatisms  are  of 
more  frequent  occurrence. 

The  haemoi'i'hages,  usually  parenchymatous  in  nature,  take  their  origin 
from  traumatisms  even  of  the  most  insignificant  kind.  Spontaneous  haemor- 
rhages have  been  observed  without  any  apparent  cau.se;  for  instance,  in  and 
under  the  skin  and  mucous  membranes,  or  from  the  stomach,  intestine,  and 
genito-urinax'y  tract.  But  these  haemorrhages  may  be  caused  by  slight  inju- 
ries of  an  unknown  nature.  At  any  rate,  parenchymatous  haemorrhages  in 
internal  organs  which  are  thoroughly  protected  almost  never  occur. 

The  traumatisms  which  produce  bleeding  in  haemophilia  are  often  of  the 
most  insignificant  kind;  for  instance,  a  trifling  pressure  on  some  jiart  of  the 
skin  will  occasion  bleeding  into  and  beneath  this  area,  brushing  the  teeth 
will  cause  the  gums  to  bleed,  and  blowing  the  nose  is  often  followed  by  a 
prolonged  nosebleed.  Of  especial  interest  are  the  ligemorrhages  into  the 
joints,  producing  a  peculiar  multiple  joint  disorder  (see  Diseases  of  Joints). 
The  bite  of  a  leech  or  an  insect,  the  prick  of  a  needle,  are  not  uncommonly 
followed  by  a  remai'kably  profuse  haemorrhage.  Fatal  haemorrhage  has 
been  observed  to  follow  the  extraction  of  a  tooth,  and  when  open  wounds 


^2\.]  THE  ACCIDENTS   DURLNG    AN   OPERATIO'N.  59 

are  made  arul  operations  are  uiulertaken  the  result  can  Ik'  imagined.  In  a 
pronounced  case  of  lueinopliilia  every  method  of  htemostasis  may  be  tried  in 
vain  and  the  patient  will  die  of  haemorrhage.  The  bleeding  may  appear  t«) 
be  stopped,  but  it  will  recur  again  and  again.  Such  a  state  may  go  on  for 
days,  weeks,  and  even  months,  but  it  generally  requires  only  a  few  days  to 
terminate  life. 

Usually,  bleeders  secui  U)  possess  a  remarkable  ])o\ver  of  withstanding  the 
loss  of  blood,  and  not  inJrequently  recover  completely  from  very  laige  ha-m- 
orrhages.  One  patient  of  Coates's  lost  twelve  kilogrammes  of  blood  in 
eleven  days.  As  the  subject  of  haemophilia  grows  older  the  intensity  of  his 
disease  seems  to  diminish,  and  in  a  few  instances  has  disappeared  entirely. 

The  prognosis  of  ha'niophilia  depends  upon  the  severity  of  trie  disease 
and  the  number  and  kind  of  traumatisms  the  individual  ma}'  he  subject  to. 
Many  sad  cases  go  to  show  that  patients  with  marked  luemophilia  often  do 
not  get  beyond  the  age  of  boyhood,  but  die  quite  young  from  some  ti-iiling 
wound  or  some  necessary  operation,  or  they  waste  away  with  marked  anaemia, 
which  is  gradually  produced  by  the  constantly  recurriiig  losses  of  blood  re- 
sulting from  the  slightest  mechanical  injury.  As  they  get  on  in  years  the 
prognosis  improves,  and  the  disease,  when  rudimentary  in  character,  may 
disappear  altogether. 

Treatment  ot  Haemophilia.— In  the  case  of  children  who  come  from 
bleeder  families  oi-  have  a  marked  tendency  to  bleeding,  prophylaxis  is  very 
important.  Every  means  should  be  taken  to  improve  their  general  con- 
dition by  good  food  and  air,  by  frequent  baths,  by  a  careful  toughening 
of  the  body,  etc.,  and  in  this  way  the  dispor.ition  to  bleeding  may  perhaps  be 
checked,  or  at  least  diminished.  The  rest  of  the  prophylactic  treatment  con- 
sists in  protecting  the  patient,  as  far  as  possible,  from  every  kind  of  trauma- 
tism which  may  give  rise  to  bleeding.  Any  trifling  mechanical  or  operative 
procedure— for  instance,  vaccination— should  be  conducted  with  the  utmost 
caution ;  operations  should  only  be  performed  in  case  of  the  most  extreme 
urgency.  Not  infrequently  bleeders  have  died  of  haemorrhage  after  an  op- 
eration, because  there  was  no  previous  knowledge  of  their  fatal  peculiarity. 

The  process  of  healing  in  bleeders  is  accompanied  by  peculiar  difficulties, 
which  are  illustrated  by  an  experience  of  Thiersch's,  who  removed  an  en- 
cysted tumour  from  the  face  of  a  bleeder  at  his  urgent  request.  The  wound 
took  six  weeks  to  heal,  and  the  patient  came  near  dying  from  the  complica- 
tions. Thiersch  recommends,  from  his  experience,  that  the  wound  be  not 
sutured,  and  that  compression  dressings  he  discarded. 

Haemorrhage  in  bleeders  is  checked  by  ligation  of  the  bleeding  vessels, 
and  when  necessary  by  the  application  of  a  solution  of  perchloride  of  iron, 
or  the  actual  cautery,  generally  in  the  shape  of  the  Paquelin  instrument. 
It  has  been  mentioned  that  bleeding  is  especially  apt  to  occur  when  the 
eschar  or  thrombus  comes  away,  and  therefore  they  should  be  kept  from 
being  disturbed  as  long  as  possible.  Thiersch,  in  his  case,  allowed  the 
wound  to  fill  with  a  blood  clot  and  surrounded  it  with  a  wall  of  compresses 
impregnated  with  ten  per  cent,  of  salicylic  acid,  and  then  wrapped  the  whole 
thing  in  a  thick  layer  of  carbolised  jute  contained  in  sterilised  gauze  without 
applying  any  pressure.  In  this  way  he  avoided  all  pressure,  and  also  pre- 
vented the  clot  from  hecoming  prematurely  loosened.     On  the  thirty-eighth 


60     GENERAL  RULES  FOR  PERFORMING  AN  ASEPTIC  OPERATION. 

day  the  clot  came  away  and  the  entire  surface  of  the  wound  was  skinned 
over.  The  internal  treatment  of  haemoi^hilia  by  ergotin,  acetate  of  lead, 
laxatives  (Glauber's  salt),  etc.,  is  useless. 

Henry  Finch,  from  a  successful  experience  with  three  cases,  advises  vene- 
section in  haemophilia  in  conjunction  with  hot-water  irrigation.  By  means  of 
the  latter  the  coagulation  of  the  blood  is  rendered  more  rapid  and  complete. 
Wright  praises  the  internal  administration  of  the  salts  of  lime  prior  to  oper- 
ation, these  salts,  as  is  well  known,  increasing  the  coagulability  of  the  blood. 

Entrance  of  Air  into  the  Veins. — The  unpleasant  consequences  of 
the  entrance  of  air  into  the  veins  should  receive  special  attention.  It 
occurs  exclusively  after  wounds  of  the  veins  in  the  neighbourhood  of 
the  thorax,  or  more  particularly  of  the  heart ;  amongst  these  veins  are 
included  the  axillary,  subclavian,  jugular,  etc.  There  is  scarcely  ever 
a  positive  pressure  in  these  veins,  and  with  every  inspiration  it  becomes 
decidedly  negative,  so  that  air  is  sucked  in  when  they  are  wounded — 
for  instance,  during  an  operation.  Added  to  this,  the  veins  in  im- 
mediate proximity  to  the  thorax  gape  open  after  being  wounded,  and 
fail  to  collapse  because  they  are  so  closely  attached  to  the  surrounding 
connective  tissue  and  fascia. 

This  is  the  case  with  the  superior  vena  cava,  sul:)clavian,  and  internal 
jugular  veins.  Death  only  takes  place  when  a  large  amount  of  air  is 
sucked  in  at  once ;  but  single  air  bubl)les  are  hannless,  as  they  gradually 
disappear  from  the  blood.  Death  from  the  entrance  of  air  into  the  veins 
has  been  explained  in  various  ways.  According  to  Conty  and  Jiirgen- 
sen,  the  air  collects  in  the  right  side  of  the  heart  and  prevents  the  con- 
traction of  the  right  ventricle,  causing  the  heart  to  stop  finally  in  dias- 
tole. The  filling  of  the  right  side  of  the  heart  prevents  the  entrance 
of  venous  blood,  thus  stopping  first  the  pulmonary  and  then  the  whole 
arterial  circulation.  According  to  others — Passet,  for  instance — the 
air  passes  from  the  heart  to  the  pulmonary  arteries,  where  it  is  arrested, 
interrupting  the  pulmonary  circulation  and  preventing  the  left  ventri- 
cle from  filling  with  fresh  blood.  According  to  a  third  theory,  air 
embolisms  in  the  cerebral  arteries  furnish  the  principal  cause  of  death. 

Recently  Hauer  has  studied  the  subject,  experimenting  chiefly  on 
rabbits,  and  has  come  to  the  conclusion  that  death  is  principally  the 
result  of  air  embolisms  in  the  small  pulmonary  vessels,  and  that  death 
can  likewise  be  caused  by  embolisms  in  the  cerebral  vessels,  as  small 
air  bubbles  pass  through  the  pulmonary  circulation  into  the  left 
ventricle.  The  introduction  of  air  into  the  veins  has  long  ])een  made 
use  of  as  a  method  of  producing  death  experimentally  in  animals. 
Rabbits  are  very  sensitive  to  air  in  the  veins,  while  in  dogs  eight  to  ten 
cubic  centimetres  of  air  can  be  injected  into  the  central  end  of  the 
jugular  vein  without  a  fatal  result. 


g22.]  TUE  POST-OPERATIVK   TREATMENT   OP   PATIENTS.  (jj 

In  man,  the  aspiration  of  air  into  the  veins  has  hitlierto  ])een  ob- 
served to  occur  })rinei])ally  during  operations  in  the  neighbourliood  of 
the  thorax  {region  dangereuse).  Greene  has  collected  sixty-seven  cases 
with  twenty-seven  recoveries,  but  a  large  proportion  of  these  are  un- 
trustworthy. The  air  is  generally  asj)irated  with  an  audil^le  sucking, 
gurgling  sound,  and  in  the  worst  cases  death  occurs  immediately.  If 
the  amount  of  air  taken  in  is  small,  the  patient  will  recover,  though 
Kunig  saw  in  such  a  case  great  anxiety,  with  laboured  breathing  and 
dilated  pupils. 

Treatment  of  Air  in  the  Veins. — Our  treatment  of  this  condition 
amounts  to  very  little.  As  proj)hylaxis,  operations  in  the  neighbour- 
hood of  the  great  veins,  particularly  in  the  neck,  should  be  conducted 
with  the  greatest  care.  If  a  large  vein  is  wounded  and  air  is  sucked  in, 
the  opening  in  the  vein  should  be  immediately  stopped  with  the  finger, 
especially  during  inspiration,  and  the  wound  filled  with  an  aseptic 
fluid,  perhaps  squeezed  from  a  sponge,  as  air  only  gets  into  the  vessel 
when  the  wound  is  dry.  Sometimes  the  air  bubbles  are  forced  out  of 
the  open  vein  during  expiration,-  and  on  this  account  Fischer  has  sug- 
gested that  vigorous  expiratory  movements  be  made  by  compressing 
the  thorax.  The  vein  is  then  to  be  ligated  as  quickly  as  possible  to 
prevent  any  further  entrance  of  air.  If  a  large  amount  of  air  has 
already  been  sucked  into  the  vein  and  has  reached  the  heart,  further 
treatment  is,  of  course,  useless,  for  death  in  such  cases  is  usually 
instantaneous. 

Other  Causes  of  Death  during  an  Operation. — These,  aside  from  the 
cases  of  actual  malpractice,  are  usually  due  to  the  large  amount  of 
blood  lost ;  to  the  particular  kind  of  operation  and  the  length  of  time 
it  takes ;  to  the  excessive  loss  of  body  heat,  especially  in  operations  in 
the  peritoneal  cavity ;  and,  finally,  to  the  constitution  of  the  patient. 
These  subjects  are  fully  discussed  in  another  chapter. 

§  22.  The  Post-operative  Treatment  of  Patients. — The  student  is 
referred  to  the  specielle  cliirurgie  for  the  after-treatment  of  individual 
operative  cases. 

The  general  treatment  of  the  patient  is  very  simple  if,  as  usually 
happens,  the  healing  process  runs  a  normal  course.  After  the  opera- 
tion has  been  performed  and  the  dressing  applied,  the  patient  is  put  to 
bed  and  surrounded,  Mdien  necessary,  with  warm  bottles,  not  too  hot, 
which  are  usually  wrapped  in  flannel  to  prevent  them  from  burning 
the  skin.  The  position  of  the  patient  should  be  as  comfortable  as 
possible,  with  especial  reference  to  the  part  of  the  body  which  has  been 
operated  upon.  Old  people,  those  sufi^ering  from  emphysema,  etc., 
should  not  have  their  head  and  thorax  placed  too  low,  as  dyspnoea  or 


62     GENERAL   RULES  FOR  PERFORMING   AN  ASEPTIC  OPERATION. 

a  hypostatic  congestion  of  the  kings  may  easily  occur.  Immediately 
after  the  operation  the  symptoms  which  are  the  result  of  the  narcosis 
become  more  or  less  prominent.     For  their  treatment,  see  page  34. 

It  is  very  important  to  take  the  temperature  two  or  three  times  a 
day  with  a  reliable  thermometer,  and  also  to  keep  run  of  tlie  pulse. 
Recovery  usually  takes  place  without  fever,  the  latter  being  the  result 
either  of  imperfect  asepsis  during  the  operation  or  of  a  fever  existing 
before  the  operation.  Every  wound  fever  is  caused  by  the  absorption 
of  toxic  substances  from  the  wound  into  the  general  circulation.  The 
so-called  aseptic  wound  fever  (Volkmann,  Genzmer),  which  probably 
depends  upon  the  absorption  of  blood  or  fibrin  ferment,  is  but  seldom 
seen.  In  general,  it  has  been  my  experience  that  in  all  cases  where 
fever  follows  operation  there  will  be  found  a  corresponding  disturb- 
ance of  the  normal  course  in  the  healing  of  the  wound.  For  the  de- 
tails of  the  nature  and  treatment  of  this  fever,  see  §  62. 

The  greatest  pains,  therefore,  must  be  expended  on  a  careful  super- 
vision of  the  healing  process.  The  dressings  should  be  changed  if  it  is 
called  for  on  account  of  fever,  pain,  or  for  the  removal  of  drainage, 
stitches,  etc.,  or  if  the  dressings  become  loosened,  displaced,  or  satu- 
rated b}'  the  secretion  from  the  wound.  The  diet  should  be  reduced 
in  quantity,  since  the  need  of  nourishment  is  less  because  of  the  rest  in 
bed  and  the  lack  of  exercise.  AVeak  individuals  should  be  given  plenty 
of  wine,  and  light,  easily  digestible,  but  strengthening  food.  For 
(piieting  the  patient  or  for  allaying  pain,  morphine  should  be  adminis- 
tered in  the  form  of  a  subcutaneous  injection  (O'Ol  to  0"02  gramme). 
But  morphine  must  be  used  with  caution ;  while  some  individuals  can 
take  very  large  doses  with  impunity,  others  will  manifest  symptoms  of 
poisoning  after  very  small  doses.  Xext  to  morphine,  the  best  hypnotic 
is  chloral  hydrate  (Liebreich),  two  to  three  to  five  grammes  of  which, 
given  in  a  glass  of  water,  will  usually  induce  sleep  very  quickly.  But 
patients  soon  get  used  to  the  drug,  and  it  then  becomes  more  or  less 
ineffectual  and  may  produce  gastric  irritation.  Of  the  new  hypnotics, 
sulphonal  and  paraldehyde  are  very  good. 

^  23.  The  Most  Important  Causes  of  Death  after  Operation  are  briefly 
as  follows:  Collapse;  shock;  anfemia;  secondary  haemorrhage ;  poison- 
ing from  the  drugs  used  with  the  dressings,  such  as  iodoform,  carbolic 
acid,  bichloride  of  mercury,  etc. ;  and  particularly  the  wound  diseases 
which  come  from  infection  with  micro-organisms — erysipelas,  pyaemia, 
and  septicaemia,  which  will  be  described  in  their  proper  places. 

We  aim  to  prevent  the  infectious  diseases  by  the  most  rigid  asepsis 
during  the  operation,  to  prevent  poisoning  by  the  cautious  use  of 
antiseptics,  and  secondary  haemorrhage  by  the  most  careful  ligation 


§23.]     MOST   IMPORTANT  CAUSES  OF   DEATH   AFTER  OPERATION.     G3 

of  bleeding  ))oiiit.s  in  the  wound.  AVe  try  to  make  the  amount  of 
blood  lost  during  the  operation  as  small  as  possible  by  the  methods 
formerly  described  (see  §  18  and  §  10).  The  best  means  to  prevent  an 
impending  collapse  from  haemorrhage  is  the  transfusion  of  defibrinated 
blood;  or,  better  still,  of  a  0*G-per-cent.  solution  of  sodium  chloride  into 
the  circulation  or  subcutaneously. 

Kecent  experiments  have  demonstrated  that  the  injection  of  a  O'G- 
per-cent.  solution  of  sodium  chloride  into  the  general  circulation  is,  on 
the  whole,  better  than  transfusion  of  blood.  (For  particulars,  see  §  89.) 
Patients  suffering  from  acute  anaemia  should  also  be  given  plenty  to 
drink,  and  wine  especially.  If  collapse  comes  on,  subcutaneous  injec. 
tions  of  camphor  (1  to  5  of  olive  oil)  and  ether  should  be  given  with  the 
hypodermic  syringe.  In  severe  cases  this  hypodermic  administration 
of  camphor  and  ether  may  be  repeated  several  times  at  intervals  of  a 
few  minutes. 

Neuroses  foUowing  Operation. — Sometimes  after  operations  neuroses 
of  the  most  varied  sort  will  occur,  especially  hysterical  phenomena, 
melancholia,  nervous  delirium,  etc.  They  are  most  common  in  nervous 
neurasthenic  subjects,  and  are  manifested  in  their  most  pronounced 
form  when  the  anjesthesia  has  been  deep  and  prolonged. 

The  Influence  of  Constitutional  Anomalies  on  the  Healing  of  the 
Wound. — Emphasis  has  justly  been  laid  upon  the  fact  that  the  wound 
will  run  the  normal  course  in  healing  if  the  operation  has  been  per- 
formed with  the  most  rigid  observance  of  asepsis. 

But  there  are  chronic  diseases,  constitutional  derangements  in  the 
nutrition  of  the  tissues,  which  occasionally  influence  the  course  of 
healing  in  the  wound  (Yerneuil,  Paget).  To  this  class  belong  espe- 
cially chronic  endarteritis,  gout,  alcoholism,  syphilis,  Bright's  disease, 
diabetes,  scurvy,  malaria,  leucaemia,  pernicious  anaemia,  the  morphine 
habit,  etc. 

Individuals  suffering  from  chronic  heart  or  kidney  disease  gener- 
ally have  little  power  of  resistance,  and  not  infrequently  collapse  after 
a  slight  and  insignificant  operation.  As  Lloyd  has  remarked,  disease 
of  the  kidney  can  be  so  intensified  by  ether  or  chloroform  narcosis 
that  threatening  symptoms  of  a  collapselike  nature  may  make  their 
appearance.  These  chronic  diseases  will  sometimes  cause  a  great 
retardation  in  the  healing  of  the  wound  made  during  the  operation. 
It.  is  well  known  how  badly  wounds  heal  in  persons  afflicted  with 
scurvy,  lucaemia,  pernicious  anaemia,  and  diabetes.  Operations  should 
be  carried  out  with  every  antiseptic  precaution  in  the  case  of  pregnant 
women ;  while  in  children  less  than  a  year  old,  as  well  as  in  the  very 
aged,  great  care  must  be  taken  to  prevent  unnecessary  loss  of  blood. 


CHAPTER  Y. 

THE    DIFFERENT    WAYS    OF    DIVIDING    THE    TISSUES. 

Division  of  soft  parts  (in  which  bleeding  occurs). — The  different  forms  of  knives. — 
The  way  to  hold  the  knife. — Instruments  to  assist  in  the  cutting  (thumb  forceps, 
hooks,  clamps). — Division  of  the  soft  parts  by  scissors. — Perforation  of  soft  parts 
by  puncture  (trocar,  hollow  needle,  hypodermic,  aspirator).  2.  The  so-called 
bloodless  division  of  the  soft  parts  with  the  assistance  of  the  ligature  ;  by  tearing 
the  parts  ;  by  compression  ;  by  the  hot  iron,  Paquelin's  thermo-cautery,  or  the  gal- 
vano-cautery. — The  destruction  or  division  of  the  tissues  by  the  use  of  chemicals 
(caustics).  3.  The  division  of  bones  by  the  chisel,  saw,  bone  forceps,  drill,  osteo- 
clast, etc. 


§  24.  The  Division  of  the  Soft  Parts  (accompanied  by  Loss  of  Blood). — 
The  soft  parts  can  be  divided  in  such  a  way  that  bleeding  may  or  may 
not  occur.  The  knife  is  the  most  frequently  used  instrument  for  divid- 
ing the  tissues.     The  most  useful  forms  are  illustrated  in  Fig.  35. 

1.  The  scalpel  with  the  blade  immovable  on  the  handle  (Fig.  35,  (i-f\ 


d  e  f  g 

Fig.  35. — Different  forms  of  knives. 


2.  Bistoury  for  the  pocket  case.     The  blade  can  be  shut  into  the 
handle  (Fig.  35,  g). 

3.  Lancet  (Fig.  35,  h).    This  form  of  the  knife  is  old-fashioned,  and 

(64) 


§24.] 


THE   DIVISION   OF   TIIK   SOFT   PARTS. 


U5 


Fig.  36. 
Conpei's 
curved 
knife. 


is  but  little  used  at  present,  except  the  .so-called  vaccination  lancet  (Fi^. 
35,  i).  It.s  point  has  a  shallow  <;i-oove  for  carrying  lymph  or  vaccine 
virus. 

As  shown  in  the  illustrations,  the  blades  of  the  scalpel  and 
bistoury  have  dilferent  shaj)es,  some  being  decidedly  or  slight- 
ly convex,  or  straight  or  curved  to  a  greater  or  less  degree. 
The  points  of  the  blades  are  also  different,  the  so-called  probe- 
pointed  knife  (Fig.  35,/')  being  blunt  at  the  end.     A.  Coop- 
er's probe-pointed  knife  (Fig.  86),  with  a  decided  curve  to  the 
blade,  is  very  useful.     Many  knives  are  double-edged  or  lance- 
shaped  (Fig.  35,  e).     We  use  the  probe-pointed  knife  in  those 
cases  in  which  we  wish  to  avoid  injury  to  the  adjoining  tissues 
by  the  point  of  the  knife.     The  length  and  breadth  of  the 
blade  varies  with  the   kind   of   operation  in  which  it  is  in- 
tended to  be  used,  the  strongest,  longest,  and  broadest  knives 
being  for  amj^utations,  disarticulations,  and  joint  resections.     For  par- 
ticular operations  there  are  especially  designed  knives.     The  handle  of 
the  knife  is  of  wood,  horn,  ivory,  steel, 
glass,  etc.,  and  the   end  is  usually  made 
like  a  chisel,  to  facilitate  tearing  through 
the   tissues   when    necessary.      A   nickel- 
plated  metal  handle  is  best  adapted  for  the 
necessary  sterilisation  of  the  knife  by  boil- 
ing in  a  one-per-cent.  soda  solution. 

The  usual  ways  of  holding  the  knife 
are  illustrated  in  Figs.  37  and  39,  but  I  do 
not  la}^  doM'U  strict  rules  when  to  use  this 
or  that  method.  No  regular  rules  are 
needed  by  any  one  having  a  natural  apti- 
tude at  operating,  or  by  any  one  wdio  is 
familiar  with  dissection.  Large  knives, 
like  those  used  for  resection,  are  held  as 
pictured  in  Fig.  39.  The  amputation  knife 
is  grasped  in  the  closed  fist,  as  in  Fig.  41. 
On  the  other  hand,  the  lancet  is  held  as  in- 
dicated in  Fig.  42. 

The  skin  is  usually  divided  as  follows  : 
After  making  the  skin  tense  by  the  thumb, 
index,  and  middle  fingers,  the  incision  is 
begun  by  the  scalpel,  held  in  the  right 
hand,  as  shown  in  Figs.  37,  38,  or  39,  and  Fio.  4o.— Method  ot  holding  the 

'  .  °  '        '  knife  when  the  tissues  are  di- 

the   blade   is   drawn   between   the  above-        vided  from  within  outwards. 

0 


Flo.  37.— Penliolder  metliod  of  using 
tlie  knife. 


Fig.  38.— Fiddle-stick  method  of 
holdino;  the  knife. 


Fig.  39. — Method  of  holding  a  large 
knife  (resection  knife). 


66 


THE  DIFFERENT   WAYS  OF  DIVIDING  THE  TISSUES. 


Fig.  41.— Method  of 
holding  a  large 
amputation  knife. 


commonly  used 

(Fig. 
many 
tions, 
sliall 


Fig.  42. — Method  of  holding  the  lancet. 


named  fingers.  Or  a  fold  of  skin  is  lifted  up  at  right  angles  to  tlie 
direction  of  the  intended  incision,  which  is  then  carried  down  through 
the  fold.  If  it  is  desired  to  make  a  long  incision  at 
one  stroke,  the  knife  should  be  drawn  rapidly  along 
without  applying  much  pressure. 

We  frequently  cut  from  within  outwards,  as  in  the 
division  of  a  fistulous  tract,  when  the  knife  is  held 
as   in   Fig.  -iO.      For   this    purpose   grooved   probes 

or  directors  are 

43).      In 
opera- 
as      we 
see,    this 
director    is    in- 
dispensable, and 
it   is   especially 

valuable  for  the  beginner.  In  such  cases  the  director  is  pushed  under 
the  particular  layer  of  tissue,  or  into  the  fistulous  opening,  and  the  point 
of  the  knife,  cutting  edge  upwards,  is  pushed  along  in  the  groove,  thus 

dividing  the  tissues.  The  cutting 
can  be  done  from  in  front  back- 
wards, or  vice  versa,  according  to 
the  case  in  hand.  In  conclusion, 
mention  should  be  made  here  of 
the  ear,  myrtle-leaf,  and  rounded 
end  probes  (Fig.  4-1,  a,  b,  c). 
These  probes  are  usually  used  for 
diagnostic  purposes,  such  as  ex- 
ploring fistulous  tracts  in  soft 
parts  and  bones,  in  the  search  for 
foreign  bodies,  such  as  sequestra, 
etc.  Probes  made  of  silver,  so 
that  they  can  be  bent,  are  the 
best.  Before  use,  every  probe 
should  be  disinfected  as  carefully 
as  possible.  There  will  be  oppor- 
tunity enough  for  warning  against 
^^^  much  probing  of  tissues,  but 
it  is  worth  while  to  give  a  general  caution  on  tliis  subject  now.  In 
searching  for  foreign  bodies  the  magnetic  needle  has  been  frequently 
used  with  success  (Kocher,  Kalin,  Lauenstein,  Graser,  and  others). 


[        h 

Fig.  44. 
Probes. 


Fig.  45. 
Tenotome. 


^  24.] 


TOE   DIVISION  OP  THE  SOFT   PARTS. 


67 


Mention  should   he  mnde  of  the  suhcntaneous  incisions  wliieh  are 
employed  for  such  cases  as  the  division  of  contracted  tendons,  club-foot, 


Fig.  46.— Toothed  forceps. 


Fig.  47. — Dressing  forcers  (a) ;  Luer's  forceps  with 
a  clasp  on  the  hundles  (b). 


etc.  The  so-called  "  tenotomy  knife  "  is  used  for  this  purpose  ;  it  is  a 
small,  sharp-pointed  knife  with  a  curved  blade  and  a  stout  handle 
(Fig.  45).  With  this  knife  the 
skin  is  punctured,  and  the  ten- 
don is  divided  beneath  the  skin 
without  cutting  through  the  lat- 
ter. 

For  holding  and  retracting 
the  tissues  after  division  of  the 
integument  we  use  particular  in- 
struments, especially  the  surgi- 
cal thumb  forceps,  clamps,  and 
hooks.  Surgical  thumb  forceps 
diiier  from  the  anatomical  kind 
in  having  two  to  four  small 
teeth  at  the  end  of  the  blade,  to 
enable  them  to  get  a  better  hold 
on  the  tissues.  Hooked  thumb 
forceps  (Fig.  46),  fitted  with 
rather  long,  curved  hooks,  are 
excellent  for   certain   purposes. 


Fig.  48. — Muzeux's  toothed  forceps :  a  without, 
b  with  a  clasp  on  the  handles. 


68 


THE  DIFFERENT   WAYS  OF   DIVIDING  THE  TISSUES. 


such  as  seizing  small  cutaneous  tumours.  The  larger  hooked  thumb 
forceps  of  this  kind  can  be  closed  and  locked  by  a  spring  (Fig-.  46,  h). 
There  are  numerous  other  kinds  of  forceps  for  grasping  the  tissues, 
sharp  and  blunt,  and  of  various  shapes  for  the  particvilar  kind  of  opera- 
tion in  which  they  are  intended  to  be  used.  Amongst  the  blunt- 
bladed  variety  are  the  sequestrum  forceps  (Fig.  47,  c/),  straight  and  bent, 
and  Luer's  forceps,  whichhave  on  the  handles  a  self-locking  ratchet  to 
hold  them  closed.  Another  kind  is  the  well-known  forceps  of  Muzeux, 
which  are  straight  or  bent,  and  are  provided  with  hooks  (Fig.  48, 
a,  l>).  These  hooked  forceps  have  from  two  to  eight  or  more  curved, 
sharp  hooks  on  the  end  of  the  blades. 

For  making  counter  openings  quickly  and  without  loss  of  blood, 
Wolfler  uses  a  cutting  sequestrum  forceps,  which  is  made  with  one 
blade  prolonged  into  a  lance-shaped  ])oint,  so  that  it  can  either  be  pro- 
truded beyond  the  other  blade  of  the  forceps  (unsheathed  perforating 
forceps),  or  by  withdrawing  the  sharpened  blade  the  latter  is  easily 
covered  (producing  the  sheathed  perforating  forceps).  The  sheathed 
forceps  are  suited  for  those  cases  in  which,  to  make  a  counter  opening, 
a  considerable  mass  of  soft  parts  must  be  traversed,  as  in  compound 

fracture,  extensive  phlegmonous 
^^^\      „       H       .==^=^  processes,   for    making    counter 

openings   at   the  bottom  of  the 
true  pelvis,  etc. 

After  making  the  skin  incision 
the  margins  of   the  wound  are 
held    apart    by   blunt    or    sharp 
hooks,  to  enable  the  operator  to 
obtain  a  better  view  of  the  deep- 
er-lying parts  or  to  divide  them, 
lietractoi's   (Fig.   49)  are   either 
.     simple,  blunt  hooks,  like  an  aneu- 
j    rism  needle  used  in  tying  a  vessel 
(Fig.  49,  a),  or  an  ordinary  sharp 
hook  (Fig.  49,  h)   with    one   or 
more  tines  (Fig.  49,  c),  or  a  blunt 
hook  bent  at  a  right  angle  (Fig.  49,  d,  e).     The  single  or  double  tined 
sharp  hooks  are  also  frequently  used  instead  of  the  thumb  forceps. 

The  scissors  commonly  used  are  straight  or  curved  (so-called  Cooper's 
scissors),  or  they  have  a  kneelike  bend.  The  various  kinds  of  scissors 
designed  for  particular  operations  are  described  in  the  book  on  special 
surgery.  The  scissors  are  held  for  operating  in  the  way  we  have 
learned  to  handle  them  in  anatomical  practice.     I  frequently  give  the 


i 


I'lK 

I 


h  r  ,/ 

Fig.  49. — Retractors. 


§24.J  THE    DIVISION   OF   TIIH   SOFT   PARTS.  69 

preforciice  to  scissors,  especially  in  the  removal  of  tinnours,  as  tliey 
facilitate  rapidity  in  operating.  Afterwards  they  con)e  into  recpiisition 
for  cutting  ligatures,  sutures,  in  the  removal  of  stitches,  etc. 

Puncture  of  the  soft  parts  can  be  done  Avith  a  pointed  knife,  or 
a  trocar  or  hollow  needle,  for  the  evacuation  of  liuid — e.  g.,  from  the 
pleural  or  peritoneal  cavities,  or  from  the  scrotum  ;  or  for  diagnostic 
j)urposes,  to  determine  the  nature  of  the  contents  of  a  cavity,  or  the 
nature  of  a  tumour;  or,  finally,  to  introduce  fiuid  medication  into  tlie 
tissues  or  general  system. 

A  trocar  (Fig.  50)  consists  of  two  parts,  a  stylet  or  trocar  with  a  handle, 
and  a  tube  or  cannida  enclosing  the  stylet.  The  cannula  is  provided  with  a 
metal  shield  at  its  posterior  extremity.  Trocars  are  straight  or  curved, 
(  the  latter,  for  instance,  being  used  for  puncture  of  the  bladder  above 
the  symphysis  pubis  in  case  of  retention  of  urine.  The  calibre  of  the 
trocar  varies  with  the  uses  to  which  it  is  intended  to  be  jnit,  the  smaller 
sizes  having  the  advantage  that  they  cause  only  a  small  puncture,  and 
the  disadvantage  that  they  take  a  long  time  to  evacuate  the  fluid;  and 
if  the  cavity   contains  a  thick  fluid,  perhaps  mixed  with   flakes  of 

fibrin,  the  liquid  may  finally  cease 
flowing  from  obstruction  in  the  can- 
nula. The  method  of  holding  the 
trocar  for  making  a  puncture  is 
illustrated  in  Fig.  50.  After  it  has 
been    introduced    far    enough,   the 

FiTbO.-Trocar.    Method  .Thoklins  tlicT^r    shield  of  the  cannula  is  grasped  by 
ill  making  a  puncture.  the  left  hand,  the  stylet  or  trocar  is 

withdrawn,  and  the  fluid  then  es- 
capes through  the  cannula,  which  is  left  in  place.  The  trocar  and  cannula, 
as  the  instrument  is  commonly  called,  must  be  used  with  every  antiseptic 
precaution;  care  must  also  be  taken  that  the  puncture  is  not  made  above  the 
level  of  the  fluid,  and  that  air  does  not  enter  the  cavity  into  which  the  in- 
strument is  introduced.  Before  using,  the  ti'ocar  and  cannula  must  always 
be  boiled  for  five  to  ten  minutes  in  a  one-per-cent.  soda  solution. 

In  former  times,  before  these  precautions  were  taken,  and  when  neither 
the  skin  area  in  question  nor  the  instrument  were  disinfected,  this  trifling 
operation  was  sometimes  accompanied  by  infection  of  the  albuminous  con- 
tents of  the  cavity,  with  ensuing  septic  inflammation.  To  prevent  the  en- 
trance of  air,  for  instance,  into  the  pleural  cavity,  Fergusson,  Fraentzel. 
and  others  have  fitted  the  trocar  with  a  certain  contrivance  which  will  be 
described  in  the  text-book  on  special  surgery  (Puncture  of  the  Pleura). 

For  diagnostic  purposes,  the  exploratory  puncture  is  made  with  a 
very  fine  trocar,  or,  better  still,  with  a  hypodermic  needle  (Fig.  53)  hav- 
ing a  tight-fitting  piston  and  joints.  After  inserting  the  hollow  needle 
of  the  syringe,  the  graduated  piston-rod  is  slowly  withdrawn,  thus  caus- 
ing the  fluid  contents  of  a  cavity  to  flow  into  the  barrel  of  the  syringe. 


TO 


THE   DIFFERENT   WAYS   OF   DIVIDIXG   THE  TISSUES. 


For  aspiration  of  the  contents  of  a  cavitv.  Dieulafoy.  Putain.  and 
others  have  made  a  suitable  apparatus  and  have  introduced  it  into 
general  use.  Syringes  have  also  been  constructed  on  the  plan  of  AVeiss's 
stomach  pump  for  syphoning  ofE  or  pumping  out  fluid  from  some  part 
of  the  bodv. 


DieTilafoy's  Aspirator  (Fig.  51)  consists  of  a  cylioder  with  a  capacity  of 
forty-five  to  fifty  grammes,  fitted  with  a  graduated  piston-rod  which  is  notched 
at  ^-1,  and,  after  being  withdrawn,  can  be  held  fast  at  B.    At  C  and  D  are  two 

stop-cocks,  which  can  be 
opened  or  closed,  and  the 
hollow  needle  is  connected 
with  the  syringe  by  a  rub- 
ber tube.  Before  punctui-- 
ing  with  the  needle  it  is 
best  to  withdi  aw  the  pis- 
ton and  form  a  vacuum 
m  the  barrel  of  the  syringe, 
so  that  during  the  opera- 
tion there  can  be  no  dis- 
turbing of  the  needle  with 
tearing  of  the  tissues. 
Both  stop-cocks  C  and  D 
are  closed;  the  piston  is 
withdrawn  and  retained 
at  B  by  turning  it  slight- 
ly from  left  to  right.  The 
cavity  of  the  cylinder  is 
The  upper  end  of  the  rubber  tube  is  then  fitted 
on  the  stop-cock  at  the  end  of  the  cylinder,  while  the  hollow  needle  at- 
tached to  the  other  end  of  the  tube  is  plunged  into  the  cavity  in  the  body 
which  it  is  desired  to  empty.  The  stop-cock  C  is  opened  and  the  liquid 
flows  into  the  cylinder.  To  empty  the  cylinder  of  the  liquid,  the  cock  C  is 
closed  and  D  is  opened,  and  by  pushing  down  the  piston  the  liquid  flows  out 
of  D.  If  necessary,  this  can  be  repeated  one  or  more  times.  Aspii*ation 
can  also  be  practised  by  thrusting  the  needle  into  the  tissues  first,  and  then, 
after  closing  the  cock  D,  opening  C,  and  by  withdrawing  the  pLston,  the  fluid 
is  allowed  to  flow  into  the  syringe.  If  the  instrument  is  in  good  condition 
and  is  managed  correctly,  it  is  impossible  for  air  to  enter  the  cavity  as  a 
result  of  the  puncture. 

Potain's  Aspirator  (Fig.  52)  consists  of  a  graduated  glass  flask  F.  which  is 
closed  by  a  rubber  stopper,  and  has  a  capacity  of  five  hundred  grammes. 
The  rubber  stopper  is  pierced  by  a  metal  tube  divided  into  two  compart- 
ments, one  communicating  with  A.  the  other  with  B.  One  rubber  tube  E 
goes  to  the  pump  G :  the  other,  which  is  fitted  with  a  glass  tube  C  to  enable 
the  liquid  to  be  seen  as  it  passes,  is  fastened  to  the  lateral  portion  of  the 
cannula  of  a  trocar.  The  cannula  is  fitted  with  a  stop-cock  D.  This  appara- 
tus is  used  in  the  following  way:   The  cock  B  is  closed.  A  is  opened,  and  a 


Fig.  51. — Dieulafoy's  aspirator. 
now  relativelv  a  vacuum. 


Fig.  52. — Potain's  aspirator. 


§24.J  THE   DIVISION   OF  THE   SOFT   PAKTS.  71 

vacuum  is  made  in  the  flask  by  means  of  tlie  pump  G  ;  tlien  A  is  closed,  and 
the  puncture  is  made  with  tlie  trocar.  The  stylet  i?  is  then  pulled  out,  and 
the  cannula  is  closed  by  the  cock  D,  while  B  is  opened,  thus  allowing  the 
liquid  to  flow  out  through  the  cannula,  glass,  and  rubber  tubes  into  the  glass 
vessel.  During  the  aspiration  the  suction  can  be  increased  by  opening  the 
cock  A  and  woiking  the  pump  G. 

The  new  aspirator  invented  by  Debove,  in  which  all  stop-cocks  are  done 
away  with,  is  a  most  excelleut  instrument.  By  a  quarter  turn  of  the  handle 
the  lateral  openings  of  the  cannula  and  trocar  can  be  made  to  correspond,  and 
thus  allow  the  fluid  to  escape.  The  apparatus  can  be  easily  cleaned  (Illustr. 
Monatssch.  der  Ai*zt.  Poly  tech.,  June.  1889  ;  this  also  contains  a  description 
of  the  automatic  aspirator  of  Ruault). 

Finally,  we  often  puncture  the  tissues  with  a  hypodermic  needle  or 
a  similar  instrument  to  introduce  morphine,  cocaine,  ether,  camphor, 
mercury,  etc.,  into  the  neighbouring  tissues  or  the  general 
system.  The  hypodermic  syringe  usually  contains  one 
gramme,  and  the  piston-rod  is  suitaljly  marked  off  to  permit 
an  accurate  measurement  of  the  amount  of  medicament 
administered.  After  tilling  the  barrel  of  the  syringe  with 
the  fluid  to  be  used,  the  hollow  needle,  having  been  care- 
fully disinfected,  is  put  in  place,  and  the  air  is  driven  out  of 
the  syringe  by  holding  the  point  upwards  and  gently  pu.-h- 
ing  on  the  piston.  To  make  the  injection,  a  fold  of  skin  is 
pinched  up,  the  needle  is  plunged  into  the  subcutaneous  tis- 
sue, the  syringe  is  emptied,  the  fold  of  skin  is  released,  the  ""Tig.  53 
needle  is  withdrawn,  the  tip  of  the  left  index  finger  is  placed   Hypodemnc 

.     .  .      .  synnge. 

upon  the  point  of  puncture,  and  the  injected  fluid  is  evenly 
distributed  by  gently  rubbing  the  area  with  the  index  and  middle 
fingers. 

For  making  parenchymatous  injections  (that  is,  injections  of  medi- 
cated fluids  into  organs — e.  g.,  muscles,  glands,  joints,  etc.)  it  is  custom- 
ary to  introduce  the  fluid  at  more  than  one  point,  particularly  if  large 
amounts  of  a  medicament  are  to  be  administered. 

The  Care  of  a  Hypodermic  Needle.— To  keep  a  hypodermic  needle  in  a 
serviceable  state,  it  should  be  washed  out  v.-ith  water  after  use.  and  the  traces 
of  fluid  should  be  blow^l  out  of  the  needle — or.  better,  dried  out  by  heating  the 
needle  in  a  spirit  lamp.  This  prevents  the  needle  from  rusting,  keeps  it  from 
becoming  stopjjed  up,  and  makes  it  unnecessary  to  introduce  a  silver  wire  for 
rendering  the  needle  pervious.  To  prevent  the  piston  from  drying  and  to 
keep  it  tight,  it  is  worth  while  to  introduce  a  drop  of  oil  occasionally  be- 
tween the  leather  washers. 

The  small  punctured  wound  made  by  the  trocar  or  hollow  needle 
can  be  covered  with  iodoform-collodion  (one  part  iodoform,  ten  parts 


72 


THE   DIFFERENT   WAYS   UF   DIVIDING   THE   TISSUES. 


collodion),  or  with  a  bismuth  and  bichloride-of-mercury  solution  ;  only 
exceptionally  would  an  antiseptic  dressing  be  necessary. 

Chronically  inflamed  tissues,  and  more  particularly  those  which  have 
undergone  caseous  degeneration,  are  removed  by  scooping  and  scrap- 
ing them  out  with  sharp  spoons  (Fig.  54).  The 
operation  is  called  "  scraping  out "  (sinuses,  fistulae, 
etc.).  Sharp  spoons  are  straight  or  slightly  bent, 
and  of  different  sizes.  The  open  raspatory  (Fig. 
54,  a),  unlike  the  sharp  spoon,  has  two  sharp  edges. 
^25.  Bloodless  Division  of  the  Tissues,  without 
Cutting,  by  Tearing,  Twisting,  etc. — Under  this 
heading  comes,  in  the  lirst  place,  the  division  of 
the  tissues,  especially  the  loose  connective  tissue, 
by  means  of  the  tips  of  the  fingers,  the  handle  of 
the  scalpel  or  the  director,  thumb  forceps,  clamps, 
etc. :  then  the  tearing  out,  or  twisting  off,  or 
squeezing  off  of  small  tumours — for  instance,  from 
the  larynx  or  the  nose — by  the  use  of  special  for- 
ceps. In  all  such  cases  the  bleeding  is  so  slight 
that  the  operation  can  in  fact  be  called  more  or 
less  bloodless.  All  large  wounds  produced  by  blunt 
instruments  bleed  but  little,  because  the  vessels  are 
twisted  and  squeezed  together  in  the  process. 

The  Division  of  the  Tissues  by  the  Ligature,  or 

riG.  54. — Sharp  spoon       „^_  ,..  .  .  .  it^ 

(Volkmann;.  StTangUiatlOn,  IS  an  antiquated  methocl  of  operatmg  ; 

it  is  too  slow,  it  is  painful,  and  not  infrequently  gives 
origin  to  inflammatory  and  even  dangerous  suppurative  processes.  In  for- 
mer times  the  ligature  was  frequently  used,  antl,  in  fact,  there  was  a  time 
when  it  was  pro^x)sed  to  amputate  the  thigh  in  this  way.  The  technique  of 
its  use  is  briefly  as  follows  :  The  particular  part  in  question — for  example,  a 
pedunculated  tumour,  a  haemorrhoidal  protrusion,  etc. — is  tightly  encu'cled 
about  its  base  by  a  .stronsr  silk  ligature  or  elastic  band,  less  frequently  by  a 
strand  of  silver  wire,  and  thus  gradually  death  (jf  the  part  takes  place.  Tlie 
elastic  ligature  is  best  secured  by  passing  its  ends,  kept  at  a  proper  tension, 
through  a  lead  ring,  the  sides  of  which  are  then  pinched  together  by  a  pair 
of  nippers.  The  silver- wire  ligature  is  applied,  and  then  retained  by  twi.sting 
the  ends  around  each  other. 

To  prevent  a  ligature  tied  about  the  base  of  a  tumour  from  slipping,  the 
base  is  ti'ansfixed  in  suitable  ca.ses  by  one  or  two  long  needles  and  the  ligature 
is  placed  beneath  them  ;  or  the  broad  base  of  a  tumour  is  tied  otf  in  two  or 
more  portions  by  transQxing  the  base  with  a  needle  bearing  a  double  ligature, 
which  is  cut  apai't  and  tied  ai*ouud  each  half  of  the  base.  In  parts  of  the 
body  like  the  pharyngeal  cavitj-  or  the  inti*avaginal  portion  of  the  uteras, 
where  the  application  of  a  ligatui-e  is  diflRcult,  special  ligature  carriers  used 


^  25.] 


BLOODLESS    DIVISION  OF  THE  TISSUES. 


73 


to  be  employed  for  applyiiiff  and  tyiug  the  ligature  (Koderik's,  De.sault's  lijra- 
ture  carrier,  etc.).  These  were  used  for  cases  like  tumours  witli  a  large,  strong 
pedicle,  in  which  the  ligature,  without  being  removed,  had  to  be  gi-adually 
tightened  to  linally  attain  the  desired  object.  Koderik's  instrument  is  fitted 
with  an  ivory  knob  perforated  for  carrying  tlie  ligature,  tlie  ends  of  which 
are  made  fast  to  a  winch.  By  turning  the  winch  the  ligature  is  shortened 
and  tightene<l.  Grafe's  ligatui'e  carrier  is  almost  exactly  similar  to  the  wire 
ecraseur  of  Maisonneuve  (Fig.  56),  except  that  a  silk  thread  is  used  instead 
of  a  wire.  As  I  have  said,  the  ligature  is  properly  considered  out  of  date  at 
present,  and  it  is  only  rarely  to  be 
used  as,  for  instance,  in  the  case  of 
individuals  who  are  hypersensitive 
about  the  use  of  a  knife,  or  for  the  so- 
called  '•  bleeders''  (see  pages  57-60). 

Ecrasement. — Ecrasement  Uneaire, 
as  it  is  called  by  Chassaignac,  wlio  de- 
vised and  iutrodviced  it.  is  also  a  form 
of  division  of  tissues  by  ligature.  The 
tissues  are  divided,  or  rather  com- 
pressed, and  thus  necrosis  takes  place 
in  the  line  of  pressure  (Fig.  55)..  Tlie 
chain  of  Chassaignac's  ecraseur  is  like 
a  chain-saw  without  teeth,  and  is  made 
to  encompass  the  portion  of  tissue  to 
be  removed,  or  is  passed  through  a  fis- 
tulous tract  by  a  probe,  or  is  canned 
through  the  parenchyma  of  an  organ 
by  a  needle,  and  so  around  part  of  the 
organ,  as  in  grasping  a  portion  of  the 
tongue.  In  the  two  latter  instances 
the  chain  of  the  ecraseur  is  first  applied 
and  then  laid  in  the  shank  of  the  in- 
strument. By  means  of  the  thumb- 
screw at  the  handle  end  of  the  instru- 
ment the  chain  ligature  can  be  short 
ened— that  is,  the  portion  of  the  tissue 
in  the  grasp  of  the  chain  is  gradually 
cut  through  by  pressure  neci'osis.  Simi- 
lar instruments  have  been  brought 
forward  by  Luer  and  Charriere.  In 
shortened  by  attaching  it  to  a  toothed  screw  which,  by  being  turned  on  a 
female  screw,  draws  on  the  ligature.  Charriere's  instrument  is  very  similar 
to  Luer  s.  except  that  the  chain  is  exposed  and  not  covered  by  a  sheath.  The 
wire  ecraseur  of  Maisonneuve  is  fitted  with  a  wire  instead  of  a  chain  ;  by 
turning  the  thumb-screw  at  the  handle  of  the  instrument,  the  loop  of  the  wire 
ligature  is  made  smaller.  Chassaignac  and  Maisonneuve  have  tried  in  vain 
to  introduce  ecrasement  more  widely  into  operative  surgery,  urging  as  ad- 
vantages of  their  method  the  absence  of  haemorrhage,  and  particularly  the 
diminished  chances  of  the  absorption  of  septic  matter,  as  the  lymphatics  and 


Fig.  55. — Chain  ecraseur  Fig.  56. — Wire  ecra- 
(Chassaignac-Mathieuj.     seur  (Maisonneuve). 

Luer's  ecra.seur  the  chain  ligature  is 


74 


THE  DIFFERENT  WAYS  OF  DIVIDING  THE  TISSUES. 


conn«^ctive-tissue  spaces  are  more  or  less  closed  by  pressure.  But  these  state- 
ments are  exaggei'ated,  since,  in  the  first  place,  there  is  no  certainty  that  the 
ecraseur.  as  it  cuts  its  way  through,  will  not  cause  hasmorrhage,  especially 
from  medium-sized  ai'teries.  Consequently  it  is  not  to  be  wondered  at  that 
ecrasement  should  be  superseded  by  the  aseptic  cutting  operation,  and  that 
it  should  have  passed  almost  entirely  out  of  use.  If  we  desire  to  divide  the 
tissues  with  as  little  loss  of  blood  as  possible,  we  now  use  the  actual  cautery, 
or,  better  still,  an  instrument  made  of  platinum  and  heated  by  the  galvanic 
current  (galvano-cautery)  or  benzene  vapour  (thermo-cautery  of  Paquelin). 

The  Cautery — The  Paquelin  Thermo-cautery. — The  division  of  the 
tissues  by  the  cautery  (red  hot  iron)  is  a  very  ancient  method,  and  in 
the  middle  ages  was  used  especially  by  the  Arabian  physicians.  The 
ordinary  cautery  is  made  of  different-shaped  iron  or  brass  rods  with  a 
wooden  handle,  and  was  formerly  heated  red-hot  among  glowing 
coals ;  but  now  it  is  usually  heated  in  the  flame  of  a  Bunsen  burner  or 
a  spirit  lamp. 

The  old-fashioned  cautery  is  at  present  entirely  supplanted  by 
Paquelin's  thermo-cautery  (Fig.  57).     Every  physician  should  possess 


Fio.  57. — Paquelin's  thermo-cautery. 

one  of  these  instruments.  The  apparatus  works  on  the  principle  that 
platinum,  after  being  sufiiciently  heated  in  the  flame  of  a  spirit  lamp, 
will  be  made  red-hot  by  the  ignition,  in  the  already  hot  platinum,  of  a 
mixture  of  air  and  vapour  of  petroleum  ether  (hydrocarbon  com- 
pounds). In  this  process  the  petroleum  ether  is  decomposed  into 
water  and  carbonic  acid,  thus  giving  rise  to  so  much  heat  that  the 
platinum  becomes  red-hot.  Paquelin's  apparatus  (Fig.  57)  consists  of 
a  glass  bottle  half  filled  with  petroleum  ether  (i^).  I  use  a  mixture  of 
two  parts  of  benzine  and  one  part  of  petroleum.     The  impure  benzine 


§25.] 


BLOODLESS   DIVISION   OP  THE  TISSUES. 


75 


is  better  tlian  that  wliich  is  chemically  pure.  By  s(jueeziiig  the  rubber 
bag  B^  the  vapour  of  petroleum  ether  is  driven  out  of  the  bottle 
through  the  rubber  tube  and  through  the  hollow  interior  of  the 
instrument  into  the  hollow  space  inside  the  platinum  tip.  The  thermo- 
cautery is  managed  very  simply :  The  point  of  the  instrument  is 
heated  in  the  ilame  of  a  spirit  lamp  for  a  couple  of  minutes,  or  long 
enough  to  reach  a  red  heat,  and  then,  by  squeezing  the  rubber  bag, 
the  benzine-petroleum  vapour  is  driven  out  of  the  bottle  into  the  plati- 
num of  the  instrument,  where  it  becomes  ignited.  In  this  way  a  verv 
excellent  cautery  is  prepared,  capable  of  very  powerful  action.  The 
most  useful  tips  are  those  with  bulbous  and  knife-shaped  extremities, 
like  the  so-called  fistula  cautery-tip  illustrated  in  Fig.  57.  Platinum 
scissors  the  blades  of  which  can  be  made  red-hot  are  not  useful,  and 
can  always  be  dispensed  wdth.  The  Paquelin  thermo-cautery  is  in 
many  respects  better  than  the  galvano-cauterv,  which  will  next  be 
described;  but  the  latter  has  the  great  advantage 
that  it  can  be  introduced  cold — for  example,  into 
the  nasal,  oral,  or  pharyngeal  cavities — and  at  any 
moment,  by  closing  or  opening  the  circuit,  it  can  be 
brought  to  a  red  heat.  The  advantage  of  the  Paque- 
lin lies  in  its  simplicity  and  cheapness.  Paquelin 
has  recently  perfected  his  cautery  so  that  it  can  be 
put  to  various  uses,  and  can  be  employed  in  min- 
eralogy, chemistry,  bacteriology,  etc. 

Galvano  -  cautery.  —  The  gal  vano  cautery  was 
brought  into  general  use  by  Middledorpf,  and  the 
excellent  instruments  that  have  been  invented  are 
of  great  service,  though  somewhat  complicated. 
The  most  important  of  this  type  of  instrument  is 
the  galvano-cautery  made  of  a  platinum  wire  sling 
(Fig.  58),  which  is  tightened  by  turning  the  ivory 
thumb-screw  C.  At  A  A  the  instrument  is  con- 
nected with  a  liattery  by  two  conducting  wires,  and 
by  closing  the  circuit  the  wire  is  brought  to  a  red 
heat.  By  pushing  the  key  £  forwards  or  back- 
wards, the  current  is  made  and  broken.  Instead  of 
the  expensive,  frail,  and  so  easily  broken  platinum 
wire,  Yoltolini  has  recommended  the  cheaper  steel 
wire  (piano  wire)  for  use  in  the  galvano  cautery, 
and  this  answers  every  purpose  perfectly. 

For  managing  the  galvano-cautery  loop  with  one  hand,  a  special 
handle  has  been  devised ;  one  of  the  best  is  that  of  Bruns,  which  has 


Fig.  58. — Galvano-caus- 
tie  loop  of  platinum 
wire. 


76 


THE   DIFFERENT   WAYS  OF   DIVIDING   THE  TISSUES. 


been  recently  improved  by  Boker  (Fig.  59).     There  are  three  rings  on 
this  handle,  for  the  tliumb,  index,  and  middle  fingers  respectively,  the 


¥i(i.  »il.— I'or- 
celain  burner. 


Fig.  59.— Handle  (Boker). 

fourth  finger  being  held  in  the  key  which  breaks  and  closes  the  cir- 
cuit. The  ring  for  the  index  finger  is  fastened  to  the  movable  cross- 
piece  to  which  the  wire  mak- 
ing the  loop  is  attached.  By 
flexing  the  index  finger,  the 
corresponding  ring,  and  with 
it  the  cross-bar  and  attached 
wire  loop,  are  drawn  towards 
the  thumb,  thus  narrowing  the 
loop.  Z  Z  represent  the  two 
wires  connecting  the  instru- 
ment with  the  battery. 
The  other  kinds  of  galvano-cauteries 
are  variously  shaped ;  besides  the  pointed 
and  straight  platinum  points,  or  those 
which  are  more  or  less  curved,  there  are 
the  spatula-shaped,  knobbed,  conical,  or 
spiral-shaped  cauteries.  By  pressing  the 
button  B  on  the  handle  (Fig.  60)  the  cir- 
cuit is  closed.  At  A  A  are  attached  the 
wires  connected  with  the  galvanic  battery. 
The  so-called  porcelain  cautery  (Fig.  61) 
consists  of  a  conical-shaped  piece  of  porce- 
lain with  a  spiral  of  platinum  wire.  As 
to  the  battery  for  working  the  gal  van  o- 
cautery,  I  use  exclusively  the  zinc-carbon 
chromic  acid  battery  of  Voltolini  (Fig.  62). 
We  shall  learn  in  the  special  surgery  the  particular  cases  for  which  the 


Flo.   fio. — Various  jralvano-cauterles 
tor  the  ear,  nose,  throat  and  larynx. 


g25.] 


BLOODLESS   DIVISION   OF   THE   TISSUES. 


77 


galvano-cautery  is  suitable.  Tt  should  only  be  mentioned  in  passin<«: 
that  even  major  operations — amputations,  for  example — have  been  per- 
formed by  the  galvano-cautery  loop  under  exceptional  conditions;  for 
instance,  to  prevent  loss  of  blood  when  a  very  high  grade  of  anaemia 
is  already  present.  Before  the  days  of  antisepsis,  llagedorn,  by  means 
of  his  ecraseur  loop,  amputated  a  leg  and  a  thigh  without  ])rimary  or 
secondary  hjx3morrhage,  and  without  applying  any  ligatures.  Brnns 
has  also  repeatedly  used  the  galvano-cautery  method  to  perform  ampu- 
tations. At  present  the  galvano-cautery  is  no  longer  used  for  ampnta- 
tions,  as  they  can  be  performed  by  tlie  knife  with  the  help  of  Esmarch's 
artificial  anaemia  without  loss  of  blood,  and  at  the  same  time  the  wound 
can  be  made  to  heal  by  primary  union  in  a  very  short  time — a  thing 
which  is  impossible  in  the  wound  made  by  the  galvano-cautery,  as  is 
always  the  case  in  a  wound  which  is  the  result  of  a  burn. 

Battery  of  Voltolini. — Voltoliui's  zinc-carbon  chromic-acid  battery  (Fig. 
62)  contains  twenty-one  zinc-carbon  elements.      The  latter  were  originally 
combined  in  the  so-called  "chain  " — all  the  cai^bon  elements  connected  ^\ilh 
each  other  on  one  side  and  all  th.e  zinc  on  the 
other.     As  this  plan  gave  but  little  healing 
power,  Voltolini  improved  the  battery  by  add- 
ing a  contrivance  (A)  for  combining  at  will 
four  pairs  of  elements,  and  thus  succeeded  in 
heating  the  porcelain  cautery-tip  red-hot.    The 
fluid  used  in  the  battery  consists  of  one  part  of 
bichromate  of  potassium,  one  part  of  concen- 
trated (not  fuming)  sulphuric  acid,  and  ten 
parts  of  water. 

To  fill  tbe  battery,  the  cover  of  the  box  is 
lifted  off  with  the  attached  elements  by  seizing 
the  handles  (B  B,¥ig.  62),  and  the  glass  vessel 
contained  in  the  box  is  half  filled  with  the 
above-described  fluid.  The  elements  are  then 
replaced  in  the  bo:;?  and  the  connecting  wires 
attached  to  the  battery  and  the  galvano-cautery 
instrument.  After  the  cover  (D)  of  the  battery 
has  been  put  back  in  its  horizontal  position, 
the  fluid  contained  in  the  glass  vessel  inside 
the  box  surrounds  the  elements  and  the  bat- 
tery is  I'eady  for  use.  If  the  cover  is  only  half  shut,  or  remains  open,  as  in 
Fig.  62,  the  glass  vessel  is  displaced  to  the  bottom  of  the  box,  the  fluid  does 
not  touch  the  elements,  and  the  battery  cannot  be  used.  The  cover  is  retained 
at  any  desired  angle  by  means  of  a  rod  fastened  to  it  on  tbe  outer  side  of  the 
box.  After  vising  the  battery  the  elements  are  taken  out  of  the  box,  carefully 
washed  off  with  water,  and  dried.  The  zinc  plates  must  occasionally  re- 
ceive a  fresh  amalgam  of  quicksilver  ;  they  are  taken  out  of  the  battery, 
dipped  in  dilute  sulphuric  acid  (1  to  7  or  10),  and  then  treated  with  pure 


Fig.  02. — Zine-carbon   chroinio-aeid 
battery  for  the  galvano-eautery. 


78  THE  DIFFERENT  WAYS  OF  DIVIDING  THE  TISSUES. 

mercury.  To  bring  the  mercury  more  thoroughly  into  contact  with  the  zinc, 
it  is  rubbed  into  the  plates  of  the  latter  with  a  tooth-brush  or  coarse  paper. 

Battery  of  Brims. — The  zinc-carbon  chromic-acid  battery  of  Bruns  is  an 
excellent  apparatus. 

Seller's  Battery. — Seiler  has  also  introduced  a  new  form  of  battery  for  the 
galvano-cautery.  It  consists  of  zinc-carbon  elements  in  a  fluid  made  of  a 
mixture  of  sulphuric  acid  and  bichromate  of  potassium;  the  elements  are  im- 
mersed in  the  fluid  by  turning  a  crank  connected  with  a  pedal.  The  opera- 
tor keeps  his  foot  upon  this  during  the  operation,  and,  by  exerting  more  or 
less  pressin-e  with  his  foot,  can  regulate  the  strength  of  the  current.  To 
protect  the  surrounding  parts  from  injury  while  the  cautery  is  heated,  Seiler 
has  sheathed  the  part  of  his  cautery  instrument  not  intended  to  become  red- 
hot,  and  the  connecting  wires  in  vulcanised  rubber. 

The  present  rapid  advance  in  electricity  enables  us  to  make  direct 
use  of  the  electric  current  without  using  a  battery ;  surgery  will  soon 
make  use  of  tliis  modern  acquisition  also,  and  thus  electrolysis  will 
have  a  new  field  opened  up  for  itself. 

All  wound  surfaces  made  by  the  cautery  bleed  but  little  or  not  at 
all,  and  are  thus  in  a  manner  protected  from  infection,  as  the  micro- 
organisms present  at  the  time  are  destroyed,  and  the  resulting  dry 
eschar  is  an  unfavourable  soil  for  the  lodgment  of  new  ones.  Moreover, 
wounds  made  by  burning  granulate  vigorously,  heal  quickly,  and  form 
a  cicatrix  which  has  a  marked  tendency  to  contract.  Suppuration  does 
not  always  occur,  and  often  enough  wounds  of  this  kind  heal  beneath 
the  eschar  with  no  dressing  and  without  noticeable  suppuration. 

Electro-puncture  (Electrolysis). — The  so-called  galvano-puncture  or 
electro-puncture  (electrolysis)  is  but  little  used  at  present.  It  consists  in 
inserting  platinum  or  gold  needles,  which  are  connected  with  the  poles 
of  a  strong  battery,  directly  into  the  tissue  but  not  too  far  apart.  The 
changes  thus  induced  in  the  tissues  are  limited  to  the  immediate  neigh- 
bourhood of  the  needles.  In  other  cases  only  a  single  platinum  needle 
connected  with  the  anode  or  cathode  is  inserted  into  the  tissues  in  ques- 
tion— for  instance,  into  a  tumour — and  a  metal  plate  connected  with  the 
other  pole  is  placed  upon  the  skin.  The  negative  pole  (the  cathode) 
appears  to  have  a  more  powerful  action  than  the  positive  (the  anode). 
Recently  electrolysis  has  come  into  more  frequent  use  for  operative 
purposes,  especially  in  the  case  of  tumours  which  are  difficult  of  access, 
like  naso-pharvngeal  tumours,  fibromata  of  the  uterus,  etc.  In  gynae- 
cology the  electrical  treatment  of  women's  diseases  inaugurated  by 
Apostoli  has  occasionally  produced  surprising  results.  I  agree  with 
Kuttner,  that  under  certain  conditions  electrolysis  oifers  us  hopes  of 
success,  by  being  applicable  to  deeply  seated  regions  when  other  means 
fail  entirely. 


§25.]  BLOODLESS   DIVISION   OF  TIIP]  TISSUES.  79 

Electro-puncture  in  Aneurism. — I  have  used  electro-punctui-e  in  cases 
of  aortic  anuurisni  with  very  good  results.  It  acts  by  exciting  coagu- 
lation of  blood  in  the  aneurismal  sac,  which  becomes  diminished  in 
size,  and  its  walls  are  distinctly  thickened.  I  use  Stohrer's  zinc-carbon 
battery,  and  regulate  the  current  by  a  dynamometer  and  a  fluid  rheostat. 
By  means  of  the  flrst  the  strength  of  the  current  can  be  determined 
each  time  it  is  used,  and  by  means  of  the  rheostat,  made  of  a  mixture 
of  concentrated  sulphuric  acid  and  oxide  of  zinc,  the  process  is  made 
as  painless  as  possible,  since  at  the  beginning  one  can  allow  the  stream 
to  increase  in  strength  very  gradually.  At  the  close  of  the  sitting  the 
current  is  made  to  gradually  decrease  in  strength  by  means  of  the 
rheostat.  A  sterilised  flne  steel  needle  ten  centimetres  long  is  plunged 
into  the  aneui-ism  with  every  antiseptic  precaution,  the  needle  being 
connected  with  the  anode,  as  the  latter  is  preferable  for  causing  coagu- 
lation of  the  blood,  while  the  other  pole  (the  cathode)  is  attached  to  a 
metal  plate  which  is  placed  on  the  skin  on  the  opposite  side  of  the 
thorax.  The  length  of  the  sitting  should  be  five  to  ten  minutes,  and  the 
strength  of  the  current  twenty  to  thirty  milliamperes. 

The  Destruction  or  Division  of  Tissue  by  Chemicals.— Caustics.— There 
are  solid,  soft,  and  fluid  caustics  which  are  used  in  the  form  of  a  paste,  pow- 
der, or  a  fluid.  At  present  caustics  are  used  much  less  often  than  formerly 
for  the  destruction  of  soft  parts.  Of  the  solid  caustics  the  most  important 
are  hydroxide  of  potassium  or  caustic  potash,  nitrate  of  silver,  and  sulphate 
of  copper  (bluestone). 

Caustic  Potash. — Caustic  potash  is  applied  in  the  form  of  a  stick  in  a 
holder,  thumb  forceps,  or  wrapped  in  a  piece  of  cotton  for  a  handle.  The 
most  useful  holder  is  an  instrument  made  like  a  pair  of  pincers,  having  hol- 
low jaws,  with  a  contrivance  for  closing  them  made  in  the  form  of  a  mov- 
able blunt  hook.  As  the  caustic  has  a  tendency  to  spread  and  "  run  "  while 
being  used,  it  is  wise  to  carefully  protect  the  surrounding  parts.  An  old- 
fashioned  way  was  to  form  an  eschar  on  the  skin  by  applying  caustics 
between  two  pieces  of  sticking  plaster,  the  one  next  the  skin  having  a  hole 
cut  in  it  to  permit  the  caustic  to  act  upon  the  skin.  Tliis  dressing  was  ap- 
plied to  any  particular  portion  of  the  skin  with  compresses  and  bandages 
for  six  to  seven  hours,  until  the  eschar  formation  was  completed. 

Nitrate  of  Silver. — Silver  nitrate  comes  in  the  form  of  a  cylindrical  pen- 
cil, which  is  generally  provided  with  a  handle,  and  is  applied  to  hasten  the 
skinning  over  of  a  granulating  surface.  The  sticks  of  silver  niti-ale— which, 
like  our  ordinary  lead  pencils,  are  enclosed  in  a  wooden  sheath— are  most  ex- 
cellent. The  so-called  "  modified  stick  "  of  silver  nitrate  is  made  of  nitrate  of 
silver  and  saltpetre  (equal  parts,  or  one  part  of  the  former  to  two  of  the  lat- 
ter). These  sticks  are  less  brittle  and  have  a  milder  action.  The  action  of 
bluestone  (sulphate  of  copper)  is  still  milder,  and  this  material  is  used  almost 
exclusively  in  diseases  of  the  eye. 

Other  Caitsfics.— Amongst  fluid  caustics  are  the  mineral  acids,  the  most 


80  THE  DIFFERENT  WAYS  OF   DIVIDING   THE  TISSUES. 

useful  being  concentrated  sulphuric  acid  and  fuming'  nitric  acid.  Besides 
these  there  should  be  mentioned  hydrochloric,  acetic,  monobrom-acetic,  and 
bichlor-acetic  acids;  also  concenti'ated  solutions  of  lactic  acid,  caustic  potash, 
bichloride  of  mercury,  chloride  of  zinc,  chromic  acid,  antimony,  etc.  The 
fluid  caustics  are  injected  into  the  tissues  by  a  hypodermic  syringe,  and  this 
can  occasionally  be  i^racticed  in  inoperable  cases,  such  as  tumours.  Of  the 
milder  caustics,  the  best  known  are  the  so-called  "Vienna  paste''  and  the 
pastes  consisting  of  arsenic  and  of  chloride  of  zinc. 

Vienna  Paste. — To  make  Vienna  paste,  five  parts  of  caustic  potash  and 
six  parts  of  quicklime  are  made  into  a  thick  paste,  immediately  before 
using,  by  the  addition  of  the  necessary  amount  of  alcohol.  The  paste  is  then 
spread  about  five  millimetres  thick,  by  a  wooden  spatula,  over  the  area 
selected  for  cauterisation,  and  allowed  to  remain  from  four  to  fifteen  minutes, 
or  until  the  desired  effect  is  obtained.  After  six  minutes  at  the  latest  there 
ax^pears  at  the  edge  of  the  paste  a  grey  line,  wliich  indicates  that  cauterisa- 
tion or  eschar  formation  is  taking  place  in  the  area  covered  by  the  paste. 
After  the  removal  of  the  paste  the  skin  which  it  covered  should  be  washed 
off  with  vinegar. 

Arsenic  Paste. — Make  a  dough  of  one  part  of  ai-senious  acid  and  fifteen 
parts  of  starcli  and  water.  The  eschar  forms  after  a  few  days,  during  which 
there  is  severe  jjain.  If  too  much  paste  is  applied  symptoms  of  poisoning  are 
very  apt  to  appear. 

Chloride-of-Zinc  Paste  {Canquoiii's  Paste). — One  part  of  chloride  of  zinc 
and  two  to  four  parts  of  flour,  according  to  the  amount  of  cauterisation  desired, 
are  mixed  with  just  enough  water  to  make  a  rather  thick,  stiff  dough.  The 
thicker  the  dough  is  spread  out  over  the  skin  the  more  intense  its  action. 
Before  applying  the  paste  the  epidermis  should  be  removed,  as  it  resists  the 
cauterising  power  of  the  chloride  of  zinc.  The  action  of  this  paste  is  very 
painful. 

Rivallie's  Caustic. — Rivallie  has  introduced  a  useful  caustic.  By  drop- 
ping concentrated  nitric  acid  upon  charpie  or  cotton-wool  in  an  earthen  vessel 
there  results  a  gelatinous  mass,  which  can  be  picked  up  with  forceps  and 
applied  to  the  skin,  and  after  a  quarter  to  half  an  hour  a  yellow  circum- 
scribed eschar  forms.  After  about  twenty-four  hours  the  eschar  can  be  in 
the  most  part  separated,  and  the  cauterisation  may  then  be  repeated.  Not 
the  smallest  amount  of  bleeding  results,  even  though  the  caustic  be  left  in 
place  for  twenty-four  hours,  and  tlie  pain  is  very  slight. 

Caustic  Points. — In  conclusion,  mention  should  be  made  of  the  method 
of  cauterisation  used  by  Maisonneuve  {cauterisation  en  fleches).  It  is  a  very 
painful  and  slow  procedure,  which  at  present  is  scarcely  ever  used.  By 
means  of  a  sharp-pointed  bistoury  the  superficial  portion  of  a  tumour  is 
incised  in  lines  radiating  to  its  base,  or  else  the  base  is  punctured  repeatedly 
all  around,  and  in  each  of  these  punctures  there  is  introduced  a  long  pointed 
solid  stick  of  some  caustic,  or  the  incisions  are  filled  with  pieces  of  cotton  or 
strips  of  linen  soaked  in  some  fluid  caustic. 

§  26.  The  Division  of  Bone. — We  use  the  so-called  raspatory  and 
periosteal  elevator  before  dividing  a  bone,  in  order  to  raise  and  so  pre- 
serve the  periosteum — as,  for  example,  in  the  subperiosteal  resection  of 


§2C.J 


DIVISION   OF   BONE. 


81 


tlie  hone  near  a  joint.     The  ends  of  raspatories — i.  e.,  their  hlades — are 
sharpened  (I'lg.  <^>'3),  and  either  curved  (Fig.  C3,  a)  or  straight  (Fig. 


1 


Fig.  63. — Raspatories :  a  and  b 
are  Langenbeck's,  c  is  Ollier's. 


m 


s 


Fio.  04. — Elevators. 


Fio.  65. — Chisels. 


63,  J,  c).  Elevators  serve  to  pry  oft'  the  periosteum  without  cutting  it. 
and  are  therefore  bhmt-edged,  and  either  straiglit  or  shghtly  curved 
(Fig.  64,  a),  or  they  are  sometimes  shaped  like  a 
goat's  foot  (Fig,  64,  h). 

To  remove  a  part  of  a  bone  or  to  completely 
divide  it,  we  use  chiefly  the  chisel  or  cutting  bone 
forceps  and  the  saw. 

Chisels  which  are  made  of  the  best  steel  have 
either  grooved  (Fig.  65,  a,  h)  or  flat  blades  (Fig. 
65,  c).  They  vary  much  in  strength,  breadth, 
and  length,  and  have  their  edge  straight  across 
or  slanting.  It  is  better  to  have  the  handle  made 
not  of  wood,  but  of  metal,  in  order  that  the  ster- 
ilisation of  the  chisel  by  boiling  may  be  more 
complete.  The  hammers  used  in  chiselling  (Fig. 
^^(^)  are  made  of  wood  or  metal.  For  dividing  the 
large  hollow  bones  I  use  the  broadest  form  of 
chisel,  as  is  recommended  by  Konig.  And  for 
these  large,  broad  chisels  I  prefer  wooden  han- 
dles, which  can  be  easily  replaced  if  they  become  damaged  by  boiling 
in  a  one-per-cent,  soda  solution.  They  are  not  to  be  applied  at  right 
7 


Fig.  66.- 


Hammers  for  the 
chisels. 


82 


THE  DIFFERENT  WAYS  OF  DIVIDING   THE  TISSUES. 


angles,  but  obliquely  to  the  long  axis  of  the  bone.     In  cases  where  it  is 
necessary  to  chisel  at  some  depth  below  the  surface,  and  it  is  impossible 


Fig.  67.— Boue  forcep.'* :  a  and  I  are  Liston's,  c  is  Kosers,  d  is  Luer's. 

« 

to  keep  perfect  control  of  the  action  of  the  chisel,  Roser  recommends 
that  the  chiselling  be  performed  with  three  hands;  i,  e.,  an  assistant 
holds  the  chisel  while  the  operator  does  the  hammering,  and  with  the 

index  finger  of  his  other 
hand  controls  the  blade 
of  the  chisel. 

The  cutting  bone 
forceps  (Fig.  67)  or 
bone  shears  (Fig.  68)  is 
used  to  remove  project- 
ing angles  or  portions 
of  bone,  or  to  complete- 
ly divide  a  flat  bone 
like  a  rib,  the  lower 
jaw,  etc.  The  rongeur 
or  gouge  forceps  of 
Liier  (Fig.  67,  d)  can 
also  be  used  for  hold- 
ing a  bone.     The  best 

Fig.   69.-  Forceps  for    forCCpS    for   grasping   a 
holding    a    bone    i^^^g      g^C,    is     that    of 

(Langenbeck).  '  ' 

Langenbeck  (Fig.  69). 
The  bones  of  children,  particularly  the  soft,  half-cartilaginous  epiph- 
yses and  spongy  bones,  like  the  carpal  and  tarsal  bones,  can  often  be 


Fig.  68. — a,  Bone-cutting  forceps;  A, 
bone-cutting  forceps  for  use  in 
resections  of  ribs. 


i;  -ifi. 


DIVISION   OP   BONE. 


83 


divided  with  a  knife.     The  sliort,  strong  resection  knife  is  tlie  best 

suited  for  this  ])ur})ose. 

For  sawing  hone  we  use 

how-saws  (Fig.  70),  narrow- 

hladed  (Fig.  71),  and  chain 

saws  (Fig.  72).     The  broad, 

tiat  saws  have  now  passed  entii-ely 

out  of  use.      Bntclier's  saw  (Fig. 

70,  h)  is  a  very  good  one ;  its  blade 

can  be  drawn  tight  or  relaxed  by 

means  of  the  screw  in  the  topmost 

crossbar,  the  latter  being  connected 

by  a  hinge  joint,  with  the  two  bars 

running  at  right  angles  from  its  extremities. 

Thus  these  two  bars,  by  means  of  the  hinge 

joint,  can  exert  traction  in  the  line  of  the 

long  axis  of  the  saw  blade,  and  the  latter 

can  make  a  curved  cut  in  bone.  For  divid- 
ing small  bones  like  the  phalanges  the  so- 
called  phalangeal  (Fig.   70,  c)  or  narrow- 

bladed  saw  is  used  (Fig.  71).    The  latter  saw  can  be  introduced  through 

a  punctured  wound   in   the   soft   parts.     The   narrow-bladed   saw  is 

grasped  in  the  closed  fist  and  the  index 
finger  is  extended  so  as  to  lie  upon  the 
back  of  the  saw.  For  many-  operations 
Adams's  narrow-bladed  saw  is  one  of 
the  best  (Fig.  71,  h).     Jeffray's  (1784) 


Fig. 


0. — cr.  Bow  saw;  ft,  Butclier's 
saw  ;  c,  iiietaearpal  saw. 


Fio. 


-Phalangeal  or  key-hole  saws: 
o,  6,  Adams's. 


Fig.  72. — Chain  saw. 


Fig.  73.— Flexible  direc- 
tor for  the  chain  saw. 


chain  saw  (Fig.  72)  consists  of  numerous  links  connected  by  hinges, 
and  each  extremity  of  the  chain  is  provided  with  a  hook  for  connect- 


84  THE  DIFFERENT   WAYS  OF  DIVIDING   THE  TISSUES. 

ing  it  with  the  handles.  The  chain  saw  is  carried  around  behind  the 
bone  either  by  the  hand,  or  a  ligature  threaded  on  a  blunt  curved 
needle,  or  a  curved  probe  with  an  eye  at  the  end,  or  bj  an  instru- 
ment like  the  one  illustrated  in  Fig.  73.  The  guide  in  Fig.  Y3  is  pro- 
vided with  an  eye  for  the  thread,  by  means  of  which  the  chain  saw 
is  brought  in  position  for  use — for  example,  behind  the  neck  of  the 
femur.  The  earlier  instruments  of  this  class  were  made  of  steel  or 
iron  ;  but  I  have  substituted  for  them  a  copper  rod  which  can  be  bent 
and  which  has  a  steel  handle,  and  thus  I  can  give  it  any  bend  I  desire. 
The  chain  saw  should  be  handled  gently,  and  with  moderate  traction 
exerted  at  the  most  obtuse  angle  possible.  If  too  mucli  force  is  used 
the  chain  may  break,  and  if  the  tension  upon  the  chain  is  uneven  it 
may  become  jammed  in  the  bone.  The  compound  chain  saw  (Heine's 
osteotome)  consists  of  a  chain  saw  which  is  stretched  in  the  form  of  an 
ellipse  over  a  tongue-shaped  metal  plate  and  is  made  to  revolve,  or 
rather  is  set  in  motion,  by  means  of  a  crank.  Heine's  osteotome  and 
similar  instruments  are  unnecessary. 

Rotation  Saws. — Oilier,  acting  on  the  suggestion  of  the  circular 
saw  so  widely  used  in  the  arts,  has  invented  a  "  rotation  saw "  which 
is  worked  by  a  crank,  and  by  means  of  which  pieces  of  bone  of  any 
desired  shape  and  size  can  be  cut  out.  The  circular  or  rotation  saw  of 
the  dentist  is  also  suitable  for  surgical  operations ;  and  mention  should 
likewise  be  made  of  the  diilerent  kinds  of  trephines  made  in  the  form 
of  a  round  saw  which  are  used  for  opening  the  skull. 

Among  other  instruments  used  in  bone  operations  are  the  sharp 
spoons  (see  page  81)  for  scraping  bone  which  has  become  inflamed  and 
broken  down ;  also  the  different  kinds  of  drills  for  making  holes  in 
bone — for  example,  to  insert  a  bone  suture  (see 
Fig.  93).  The  bone  files  for  smoothing  and 
rounding  off  the  edges  of  a  bone — for  instance, 
after  it  has  been  sawed  across — are  no  longer 
used,  but  their  place  has  been  taken  by  the  sim- 
ple chisel  or  Liston's  bone  forceps. 

Osteoclasis. — Either  the  hands  of  the  operator 

or  special  instruments  (osteoclasts)  are   used  to 

fracture  a  bone  (osteoclasis)  when,  for  exan)ple, 

a  fracture  has  healed  in  a  faulty  position,  or  when 

there  is  a  curvature  of  bone  resulting  from  rha- 

eiast.  ^  chitis.      Collin,  Ilobin,  Molliere,  Ferrari,  Beely, 

and  Gratteau  have  each  devised  osteoclasts. 

Rizzoli's  apparatus  (Fig.  74)  consists  of  two  rings  sliding  on  an  iron 

bar,  to  which  they  can  be  made  fast  at  any  point  by  means  of  a  thumb- 


g'36.]  DIVISION   OF    BONE.  85 

screw,  and  in  these  riii^s  the  extremity  is  placed.  The  "stamp" — i.  e., 
the  lower  end  of  the  screw-j)in — is  applied  at  the  point  where  it  is 
desired  to  break  the  hone  transverse!}',  J>y  turnin<^  the  lever  the  j)in 
is  screwed  down  and  the  stani[)  fractures  the  hone.  The  skin  sliould 
he  carefully  protected  at  the  diifei-ent  points  of  ])i"essure  by  means  of 
cotton  or  jute  pads.  In  si)ito  of  the  manifold  improvements  in  the 
osteoclasts  the  instruments  cannot  even  yet  ije  relied  upon  to  do  all 
that  their  inventors  claim.  Above  all,  it  is  very  difficult  to  fracture  a 
bone  at  exactly  the  desired  spot,  especially  if  it  is  in  the  neighbourhood 
of  a  joint,  without  doing  some  injury  to  ihe  soft  parts. 


CHAPTER  VI. 

THE    METHODS    OF    ARRESTING    HAEMORRHAGE. 

The  tying  of  vessels  (ligation). — Artery  clamps. — The  preparation  of  aseptic  ligature 
material  (catgut,  silk,  etc.). — The  substitutes  for  ligation. — Torsion. — Deep  suture. 
— Temporary  occlusion  of  the  lumen  of  the  vessel  by  artery  clamps. — Ligature 
of  a  part  of  a  vessel's  wall  and  suture  of  veins. — Pressure. — Packing. — Cauterisa- 
tion.— Other  methods  of  controlling  hjemorrhage. — Irrigation  with  hot  and  cold 
water. — The  suture  of  the  wound,  with  application  of  pressure  by  the  dressings 
as  a  means  of  stopping  hannorrhage. — Old-fashioned  and  no-longer-used  methods 
of  stopping  htTmorrhage  (acupressure,  acutorsion,  etc.). — Ligature  of  vessels  in 
their  continuity.  See  also  §§  18  and  19  (Prevention  of  Ha?morrhage  in  Opera- 
tions, Esraarch's  Artificial  Ischfemia). 

§  27.  The  Arrest  of  Hsemorrhage  during  Operations. — ^We  distinguish 
between  arterial,  venous,  and  capillary  or  parenchyuiatous  ha^niorrliage. 
AYe  will  here  discuss,  in  the  first  place,  the  arrest  of  haemorrhage  dur- 
ing an  operation. 

The  arrest  of  haemorrhage  from  a  wound  made  in  the  course  of  an 
operation  must  be  most  carefully  attended  to,  in  order  that  no  second- 
ary hemorrhage  may  interfere  with  the  healing  of  the  wound  or  en- 
danger the  life  of  the  patient.  It  is,  in  general,  an  indispensable  requi- 
site for  obtaining  perfect  primary  union  that  all  haemorrhage  should 
be  checked  completely.  In  the  presence  of  dangerous  hremorrhage 
the  qualities  of  a  surgeon  are  revealed  ;  coolness,  presence  of  mind, 
and  complete  familiarity  with  the  technique  of  operating  are  indis- 
pensable. We  have  already  learned,  in  the  consideration  of  Esmarch's 
bloodless  method,  in  what  way  serious  haemorrhages  may  be  prevented 
in  any  operation. 

The  first  step  in  accurately  checking  haemorrhage  consists  in  tying 
off  (ligation  of)  the  vessels,  both  veins  and  arteries,  which  have  been 
wounded  in  the  course  of  the  operation.  In  the  preantiseptic  days  of 
surgery  there  was  great  dread  of  ligating  veins,  on  account  of  the  fre- 
quency of  the  ensuing  suppurative  changes  which  took  place  in  the 
thrombi,  resulting  in  a  general  systemic  infection  (pyaemia)  and  death. 
Modern  antiseptic  surgery,  however,  has  no  fear  of  ligating  veins,  and 
secures  every  bleeding  vessel.     If,  for  example,  in  a  high  amputation 

(86) 


§27.]      THE   ARREST   OF    HAEMORRHAGE   DURING   OPERATIONS.  87 

of  tlie  tlii»5h,  or  di-sarticulation  of  the  femur,  the  femoral  vein  is  not 
ligated,  it  is  perfectly  possible  for  dangerous,  recurrent,  or  secondary 
hjemorrhages  to  take  place ;  and  as  a  matter  of  fact  this  has  been 
observed. 

Attempts  to  diminish  or  prevent  haemorrhage  during  an  operation  are  as 
old  as  surgery  itself.  We  recall  with  a  shudder  the  times  when  amjRitation 
of  a  limb  was  performed  with  a  red-hot  knife,  or  when  the  ami)utati()n  stumj^ 
was  plunged  into  melted  i)ilch  to  check  the  bleeding.  The  skilful  surgeons 
of  the  time  of  the  Roman  Empire  understood  the  treatment  of  haemorrhage 
better  than  the  physicians  of  the  middle  ages,  were  familiar  with  the  liga- 
ture, and  even  used  artery  clamps.  All  this  was  entirely  forgotten  during 
the  middle  ages,  and  Ambrose  Pai-e  reintroduced  the  ligation  of  vessels  in 
the  sixteenth  century. 

"We  tie  off  or  ligate  tlie  vessels  in  the  wound  by  seizing  their  open 
ends  with  so-called  artery  clamps   or   haemostatic  forceps  which  are 


Fig.  75.— Haemostatic  forceps  or  clamps. 

closed  and  locked  by  a  suitable  contrivance.  The  clamps  which  I 
consider  the  best  are  illustrated  in  Fig.  75,  some  being  open  and  some 
closed.  The  Fricke-Amussat  clamp  (Fig.  75,  a,  h),  which  is  fastened 
by  means  of  a  small  sliding  piece  the  end  of  which  fits  into  a  ring 
in  the  other  jaw  of  the  forceps,  and  Pean  and  Ivceberle's  forceps,  wliich 
have  a  ratchet  lock  on  the  handle,  are  the  most  useful  forms  of  the  in- 
strument. 

By  means  of  the  haemostatic  forceps  or  clamps  the  isolated  end 
of  the  vessel  is  seized,  and,  if  necessary,  the  surrounding  tissues  are 
stripped  back  and  the  vessel  is  carefully  encircled  with  catgut  or  silk, 
which  is  then  tied  beyond  the  clamp.  In  the  case  of  large  arteries  the 
ligature  should  be  tied  in  a  double  square  or  surgeon's  knot ;  but  small 


88 


THE  METHODS  OP  ARRESTING  HEMORRHAGE. 


vessels  only  require  tlie  ordinary  simple  knot.  The  ends  of  the  liga- 
ture are  cut  short  after  the  clamp  has  been  first  removed  to  see 
whether  the  knot  holds  securely  and  whether  there  is  any  danger  of  its 
slipping.  The  surgeon's  knot  is  made  by  twisting  one  end  of  the  liga- 
ture around  the  other — not  once,  as  in  tying  the  ordinary  knot,  but 
twice.  The  application  of  ligatures  en  masse,  as  they  are  called, 
about  the  vessel  and  the  surrounding  tissue  should  be  avoided  as  much 
as  possible.  Instead  of  hsemostatic  forceps  or  clamps,  sharp-pointed 
hooks  are  sometimes  used  to  draw  out  the  end  of  the  vessel.  Liga- 
tures are  made  of  catgut,  which  was  first  recommended  by  Lister,  and 
which  is  manufactured  from  the  intestine  of  the  cat  or  sheep,  and  silk 
which  has  been  sterilised  by  boiling. 

Preparation  of  Aseptic  Catgut. — Catgut  can  be  prepared  for  use  aseptic- 
ally  in  various  ways.  If  the  hot-air  sterilisation  plan  of  Doderlein,  Kunirael, 
and  others  is  used,  the  raw  catgut  must  first  be  soaked  for  twenty -four  to 
forty-eight  hours  in  absolute  alcohol  to  remove  all  water.  Then  the  catgut 
is  put  in  a  glass  jar  or  between  layers  of  blotting  paper  and  placed  in  the 
stei'ilising  apparatus,  which  is  very  gradually  heated  to  a  temijerature  of 

1.30°  C.  After  this  it  is 
placed  for  six  to  eight  days 
in  oil  of  juniper  which  has 
also  been  sterilised  by  heat, 
and  then  it  is  stored  for  use 
in  a  one-per-cent.  alcoholic 
solution  of  bichloride  of 
mercury  or  in  a  ten-per- 
cent, solution  of  carbolic 
acid  in  glycerin,  or  in  a 
l-to-5()0  aqueous  solution 
of  bichloride  of  mercury. 
Brunner  places  the  catgut 
in  xylene  in  a  closed  vessel, 
and  subjects  this  to  the  ac- 
tion of  steam  at  a  tempera- 
ture of  100°  C.  (212°  F.)  for  three  hours.  The  catgut  is  then  washed  in  alco- 
hol and  stored  in  an  alcoholic  solution  of  bichloride  of  mercury.  According 
to  my  experience,  the  hot-air  sterilisation  of  catgut  is  difficult  and  trouble- 
some, and  I  prefer  the  bichloride  method  of  treating  it  devised  by  Schimmel- 
busch  and  Bergmann  after  the  catgut  has  been  previously  rendered  free  of 
fat  by  soaking  in  ether.  The  sterilisation  is  accomplished  as  follows  :  the 
glass  vessel  and  the  glass  spools  are  sterilised  by  steam  for  three  quarters  of 
an  hour;  the  raw  catgut,  which  contains  fat,  is  i-olled  on  the  spools  and  soaked 
for  twenty-four  hours  in  ether,  which  is  then  poured  off  and  replaced  by  an 
alcoholic  solution  of  bichloride  of  mercury  (ten  parts  of  bichloride,  eight  hun- 
dred parts  of  absolute  alcohol,  and  two  hundi'ed  parts  of  distilled  water),  which 
is  renewed  at  the  end  of  twenty-four  hours.    According  to  whether  one  desires 


1  2  3 

Fig.  76. — Vessels  for  storing  sterilised  catsrut  and  silk :  1, 
Glass  case  with  glass  spools  for  hospital  practice ;  2  and 
3,  glass  bottles  with  glass  rollers  and  india-rubber  stop- 
pers for  private  practice  (see  also  Fig.  14). 


^21.]     THE  ARREST  OP   HAEMORRHAGE   DURING   OPERATIONS.         89 

stitf  or  pliable  catgut,  the  latter  is  stored  in  absolute  alcohol,  or  iu  a  tweuty- 
per-cent.  mixture  of  glyceriu  and  alcohol,  or  in  the  alcoholic  solution  of 
bichloride  just  described.  In  this  way  a  very  stronj^,  flexible  catg-ut  is  ob- 
tained which  is  aseptic,  and  more  desirable  in  every  way  than  the  carbolised 
catg'ut  formerly  used,  which  was  not  aseptic,  and  occasionally  gave  rise  to 
suppuration,  pyjpiuia,  and  septicremia  (Zweifel.  Kocher). 

Chromicised  Catgut,  which  is  more  slowly  absorbed,  is  prepared  from 
commercial  raw  catgut  by  subjecting  it  to  a  dry  heat  of  130''  C.  (20G°  F.),  and 
keeping  it  for  forty-eight  hours  in  a  ten-per-cent.  solution  of  cai-bolic  acid  in 
glycerin,  and  then  for  five  hours  iu  a  one-half-per-ceut.  solution  of  chromic 
acid.  It  is  stored  in  a  five-  to  ten-per-cent.  solution  of  carbcjlic  acid  in  glyc- 
erin, or  in  a  one-per-cent.  alcoholic  solution  of  bichloride  of  mercury,  and 
immediately  before  use  it  is  placed  in  a  three-per-cent.  aqueous  solution  of 
carbolic  acid  or  bichloride  of  mercury.  Macewen  keeps  the  raw  catgut  for 
two  months  in  a  mixture  of  twenty  parts  of  glycerin  and  one  part  of  a  twen- 
ty-per-cent.  aqueous  solution  of  chromic  acid.  He  then  washes  it  and  stores 
it  in  a  twenty -per-cent.  solution  of  carbolic  acid  in  glycerin. 

Braatz  uses  the  following  method  for  sterilising  catgut:  the  raw  catgut  is 
soaked  in  ether  or  chloroform  for  one  or  two  days,  to  free  it  from  fat ;  it  is 
then  placed  for  twenty -four  hours  in  an  aqueous  solution  of  bichloride  of 
mercury  (1  to  1,000),  or  else  sterilised  by  Reverdin's  dry-heat  method  (page 
88),  and  then  stored  in  absolute  alcohol.  Many  sui'geons  preserve  their 
sterilised  catgut  in  a  dry  state — for  example,  between  layers  of  sterilised  com- 
presses, or  in  a  glass  jar  (Esmarch,  Mikulicz). 

According  to  the  investigations  of  Brunner,  the  catgut  sterilised  by  treat- 
ment with  bichloride  of  mercury,  or  by  dry  heat,  is  perfectly  sterile,  while 
the  catgut  treated  with  carbolic  acid,  chromic  acid,  and  oil  of  juniper  contains 
many  fungi  and  bacteria.  Bi^unner  recommends  the  following  method  of 
sterilisation :  the  catgut  is  first  washed  with  soft  soap,  and  then,  either  im- 
mediately or  after  soaking  for  half  an  hour  in  ether,  it  is  transferred  to  an 
aqueous  solution  of  bichloride  (1  to  1,000),  where  it  is  left  for  twelve  hours. 
It  is  then  stored  in  bichloride  of  mercury  one  part,  absolute  alcohol  nine 
hundred  parts,  glycerin  one  hundred  parts. 

Preparation  of  Carbolised  and  Bichloride  Silk.— The  carbolised  and  bi- 
chloride silk  is  prepared  by  winding  the  silk  on  hollow  glass  spools  and  then 
boiling  it  for  half  an  hour  in  a  five-per-cent.  aqueous  solution  of  carbolic 
acid,  or  a  l-to-500  solution  of  bichloride  of  mercury.  After  this  it  is  stored  in 
a  five-per-cent.  aqueous  solution  of  carbolic,  or  a  l-to-2,000  solution  of  bi- 
chloride of  mercury,  or  in  absohite  alcohol.  An  aseptic  silk  ligature  remains 
in  a  wound  as  a  foreign  body,  but  without  causing  any  reaction. 

Catgut  has  long  been  used  for  the  ligation  of  vessels  as  well  as  for  suture 
material,  and  for  the  latter  purpose  was  used  by  Rhazes,  while  Hennen  and 
Young  (1813),  Lawrence  (1814),  and  A.  Cooper  (1817)  used  it  for  tying  vessels. 

Ligatures  of  Other  Materials.— Besides  catgut  and  silk,  ligatures  are  made 
of  chamois  leather  or  parchment,  fi'om  the  aorta  of  the  ox,  from  horse-hair, 
and  from  the  tendons  of  mammals  like  the  kangaroo,  whale,  reindeer,  etc. 

Catgut  is  ahsorbed  and  disajDpears  without  leaving  a  trace,  wliile 
silk,  on  the  other  hand,  remains  unclianged.     For  ligation  of  the  large 


90 


THE  METHODS  OF  ARRESTING  HEMORRHAGE. 


arteries  and  veins  I  prefer  aseptic  silk  to  catgut,  as  the  latter  may  be 
absorbed  too  quickly  before  the  cicatricial  closure  of  the  lumen  of  the 
vessel  has  become  sufficiently  lirm.  Moreover,'  silk  can  be  sterilised  by 
boiling  with  greater  certainty  than  is  possible  in  the  case  of  catgut,  and 
much  finer  ligatures  of  silk  than  of  catgut  can  be  used  even  for  large 
arteries. 

§  28.  Substitutes  for  the  Ligation  of  Vessels. — Torsion  of  the  End  of 
the  Artery  (Ami(ssat),  and  Deep  Suturiny. — Torsion  of  the  cut  end 
of  a  vessel  is  performed  by  seizing  the  end  in  a  haemostatic  clamp  and 
twisting  it  several  times  on  its  long  axis.  The  lumen  of  the  vessel  is 
thus  closed  by  rolling  up  and  tearing  the  walls  of  the  vessel,  especially 
the  middle  and  inner  coats.  Torsion  produces  more  accurate  closure 
of  the  lumen  of  the  vessel  if  the  latter  is  grasped  by  two  clamps — one  at 
the  end  of  the  vessel  and  held  in  its  long  axis,  the  other  clamp  behind 
the  first  and  at  right  angles  to  the  vessel.  The  first  clamp  is  then 
twisted  till  the  portion  of  the  vessel  to  which  it  is  attached  gives  way. 
Arteries  as  large  as  the  brachial  can  be  so  firmly  closed  by  torsion  that 
no  bleeding  will  occur.  But  if  branches  are  given  off  close  above  the 
bleeding  end  of  the  artery,  the  latter  will  not  be  sufficiently  movable  to 
make  torsion  safe,  and  on  this  account  torsion — for  instance,  of  the 
femoral  artery — is  usuallv  impracticable. 

Torsion  is,  as  a  general  thing,  only  used  for  small  vessels.  Stilling 
recommends  drawing  the  end  of  the  artery  through  a  puncture  made 
in  the  artery  wall  (Fig.  77). 

Deep  Suture  around  a  Vessel  ("  Umstecliung "). — A  suture  passed 
through  the  tissues  around  a  vessel  is  similar  to  a  ligature  eji  masse,  be- 


Fio.  77. — "  Durchschlincfung"  of 
an  artery  fStlllingj. 


Fig.  78.—"  Umstecbung  "  of  vessels. 


cause  the  surrounding  tissues,  as  well  as  the  vessel  itself,  are  included 
in  the  ligature  fFig.  78).  A  sharply  curved  needle,  carrying  a  ligature, 
is  passed  through  the  tissues  so  that  the  points  where  it  enters  and 
emerges  lie  close  together.     This  method  is  applicable  for  those  cases 


^•28.]  SUBSTITUTES  FOR  THE    LlGATiOxN    OF   VESSELS.  91 

in  wliich  the  Lleediiig  end  of  the  vessel  lies,  for  instance,  in  stiff,  un- 
yielding tissues,  or,  for  one  reason  or  another,  cannot  be  bufticiently 
isolated  for  the  application  of  a  scj)arate  ligature, 

Haemostasis  by  passing  a  Suture  through  the  Skin  into  the  Parts  around 
a  Vessel. — Middli'durj-fs  method  of  pah:siiif^  a  suture  throujih  the  skiu  and 
around  a  vessel  is  at  best  only  a  temporary  expedient.  For  example,  in 
bleeding'  from  the  temjjoi'al  ai-tery  a  curved  needle  carrying  a  ligature  can  be 
passed  through  the  skiu  under  the  vessel  and  then  knotted  upon  the  skin.  A 
siunlar  plan  is  sometinu  s  a(h)pted  to  I'ender  oi)erations  on  tlie  tongue  blood- 
less. At  the  end  of  the  operation,  when  the  wound  in  the  tong'ue  has  been 
closed  by  sutures,  this  ligatui-e  en  matise  is  removed. 

Temporary  Occlusion  of  the  Vessels  by  Clamps.— For  cases  in  which  the 
application  of  a  ligature  is  dillicult  or  impossible,  it  may  be  expedient  to  oc- 
clude the  lumen  of  a  vessel  by  a  haemostatic  clamp,  which  is  left  in  place 
for  some  time.  Kceberle  and  Pean  have  found  the  lumen  of  vessels  per- 
fectly closed  after  the  expiration  of  twenty-four  hours  with  this  method  of 
haemostasis. 

Simple  punctures  or  slits  in  the  wall  of  a  large  vein  have  been  closed  by 
the  ajiplicatiou  of  a  ligatui-e  to  the  side  of  the  vessel.  The  injured  portion  of 
the  vein  is  seized  by  a  clamp,  and,  while  sligrht  traction  is  made  upon  it,  a 
ligatiu'e  is  tied  around  the  puncture  beyond  the  jaws  of  the  clamp,  and  thus 
the  whole  lumen  of  the  vessel  is  not  occluded.  This  lateral  ligature  is  but 
little  used,  as  it  easily  slips.  If  a  large  vein,  like  the  common  femoral,  has 
been  punctured,  and  there  is  fear  of  gangrene  of  the  lower  extremity  if  the 
whole  vein  is  tied  off,  it  is  best  to  close  the  puncture  temporarily  with  an 
artery  clamp  or  by  Schede's  method  of  suturing  with  fine  catgut.  Schede 
has  repeatedly  sutured  veins  by  means  of  the  finest  needles  and  catgut  with 
excellent  results.  Under  this  heading  come  suture  of  the  femoral,  inferior 
vena  cava,  axillary,  jugular,  etc. 

Experimental  Investigations  on  the  Suture  of  Arteries  and  Veins.— The 
experiments  of  Horoch  prove  that  suturing  an  artery,  as  well  as  ligating  it, 
results  in  a  perfect  closure  of  the  Ivxmen  of  the  vessel  by  means  of  a  clot. 
But  ligation  causes  immediate  occlusion  of  the  vessel,  while  suturing  causes 
occlusion  to  take  place  slowly.  Catgut  is  not  suitable  for  sewing  an  artery, 
but  only  fine  silk  should  be  used.  If  a  vein  is  sutured,  the  lumen  persists  to 
a  greater  or  less  degree,  and  consequently  Horoch  prefers  suture  to  the  appli- 
cation of  a  lateral  ligature,  as  the  experiments  of  Blasius  show  that  lateral 
ligation  of  a  vein  reg'idarly  causes  occlusion  of  the  latter's  lumen  by  a  throm- 
bus. Jassinowsky,  Burci,  Mi;scatello,  and  others  have  also  made  experiments 
with  suturing  a  partially  divided  artery  in  animals,  and  have  obtained  satis- 
factory results.  With  the  aid  of  the  sutures  the  wound  in  the  artery  unites 
by  primary  intention,  and  there  is  no  haemorrhage  following  the  operation. 
Secondary  haemorrhage,  thrombosis  (contrary  to  Horoch's  experience),  and 
the  formation  of  aneurisms,  do  not  occur.  The  lumen  of  the  vessel  where 
the  suture  was  applied  remains  entirely  free.  Suturing  of  the  vessel's  wall  is 
particularly  applicable  in  longitudinal,  oblique,  and  "flap"  wounds,  provided 
that  not  more  than  half  the  circumference  of  the  large  vessel  is  involved  in 
the  wound.     The  most  rigorous  asepsis  is  absolutely  essential  for  success  in 


92 


THE   METHODS  OF   ARRESTING    HEMORRHAGE. 


suturing  a  portion  of  the  wall  of  an  ai'tery,  for  which  the  finest  silk  is  used 
in  the  form  of  a  continuous  suture  passed  gently  through  the  adventitia  and 
media.    Hitherto  suture  of  an  artery  in  man  has  never  been  practically  tested. 

§  29.  Other  Methods  of  Hsemostasis. — Another  most  important  meth- 
od of  haemostasis  \s> pressure,  which  we  apply  in  many  different  ways, 
and  which  is  evidently  the  simplest  and  most  natural  way  of  checking 
haemorrhage.  Whenever  during  the  course  of  an  operation  blood 
gushes  forth  from  a  divided  vessel,  we  immediately  place  our  finger 
upon  the  bleeding  point  and  so  stop  the  haemorrhage.  It  is  singular 
that  this  simple  method  of  haemostasis  is  so  little  understood  by  the 
laity  ;  when  they  meet  with  dangerous  bleeding,  perhaps  from  a  punc- 
tured wound  of  one  of  the  larger  arteries,  they  are  very  apt  to  employ 
the  strangest  remedies,  such  as,  for  example,  the  application  of  cobwebs 
and  similar  things.  Pressure  is  also  practised  as  a  temporary  means  of 
hfemostasis  in  the  form  of  digital  compression  (mentioned  in  §  18,  p. 
47)  of  the  afferent  artery,  and  by  means  of  rubber  bandages,  tourni- 
quets, etc.  In  suitable  cases  pressure  can  be  combined  with  forced 
flexion  of  the  neighbouring  joint — as,  for  example,  in  bleeding  in  the 

popliteal  space  the  knee  joint  is  im- 
mobilised in  extreme  flexion  (Fig. 
T9),  or  haemorrhage  from  near  the 
elbow  can  be  held  in  check  by  im- 
mobilisation of  the  elbow  joint  in  a 
position  of  extreme  flexion. 

Pressure  is  the  ordinary  method 
of  haemostasis  used  for  stopping  pa- 
renchymatous bleeding.  The  wound 
is  compressed  for  a  time  with  aseptic 
sponges,  or,  if  it  occurs  in  a  cavity, 
the  latter  is  filled  with  some  aseptic 
dressing  material  such  as  iodoform 
gauze  (the  wound  is  packed),  or  an 
ordinary  dressing  is  bound  on  so  as 
to  exert  pressure. 
Packing. — A  wound  or  a  bleeding  cavity,  like  the  nose  or  rectum,  is 
"  packed  "  by  filling  it  as  tightly  as  possible  with  antiseptic  dressing 
materials  like  iodoform  gauze.  In  haemorrhage  from  the  rectum,  a 
large  scpiare  piece  of  bichloride  or  iodoform  gauze  is  seized  in  the 
centre  with  the  fingers  or  blunt  forceps  and  pushed  up  into  the  rectum 
in  the  form  of  a  purse  or  empty  bag,  and  into  this  strips  of  iodoform 
gauze  are  forced  until  the  bag  is  full.  The  strips  or  pads  of  iodoform 
gauze  can  be  fastened  to  a  string  and  then  packed  in  place.     The  col- 


Fio.  79.  — Forced  flexion  nf  tin-  kiuc  lor  tem- 
porary aiTest  of  liajuiorrliage  in  the 
popliteal  space. 


§20.]  OTllKR  METHODS   OF   ILEMOSTASIS.  93 

peurynter  can  also  be  used  in  the  reetiun.  It  consists  of  a  rubber  blad- 
der to  which  a  tube  is  connected,  the  former  beint^  introduced  cni])ty 
into  the  rectum  and  then  lilled  by  a  syringe  with  warm  water  or  air 
forced  through  the  tul)e,  which  is  finally  closed  by  a  compression  for- 
ceps.   The  elastic  bladder  works  in  the  same  way  as  the  gauze  packing. 

Cautery. — Of  the  other  methods  for  luemostasis  the  hot  iron  is  the 
most  important,  the  best  form  of  which  is  Paquelin's  thermocautery 
(Fig.  57,  p.  74)  or  Middledorpf's  galvano-cautery  (p.  75).  The  firm 
eschar  of  the  burn  prevents  the  escape  of  blood.  The  hot  iron  is 
usually  only  suitable  for  bleeding  from  small  vessels  which  cannot  be 
ligated.  It  should  be  used  at  not  more  than  a  red  heat,  so  as  not  to 
burn  the  tissues  too  rapidly,  but  simply  to  char  them  slowly. 

Styptics. — Amongst  the  fluid  remedies  for  checking  haemorrhage 
mention  should  be  made,  in  the  first  place,  of  the  liquor  feri'i  sesqui- 
chlorati,  which  makes  a  firm  coagulum  with  blood.  A  pledget  of  cot- 
ton or  gauze  is  soaked  in  it  and  applied  to  the  bleeding  spot  as  firmly 
as  possible  for  one  or  tM^o  minutes.  This  procedure  must  usually  be 
repeated  one,  two,  or  three  times.  Styptic  cotton,  as  it  is  called,  is 
simply  cotton  which  has  been  soaked  in  liquor  ferri  sesquichlorati  and 
dried.  The  material  made  from  the  Boletus  igniarius  dind  the  Peng ha- 
war  djarnhl  is  very  similar  to  styptic  cotton,  and  consists  of  the  light- 
brown  hairs  from  the  stem  of  the  Cihotiurn  cuininghii^  an  East  Indian 
plant.  If  this  is  applied  in  sufticient  amount  to  the  wound  surface  and 
with  enough  pressure,  it  makes  a  very  good  styptic.  Noltenius  has 
recommended  a  penghawar  cotton  consisting  of  a  mixture  of  Pengha- 
war  djamhi  with  cotton  and  ten  per  cent,  of  iodoform.  All  styptics 
producing  an  eschar  prevent  primary  union  of  the  wound.  Under 
fluid  haemostatics  there  are  still  to  be  mentioned  vinegar,  solutions  of 
alum,  turpentine,  and  aqua  Binelli.  Wright  recommends  a  solution  of 
flbrin  ferment  with  one  per  cent,  of  chloride  of  lime  as  a  useful 
haemostatic,  which  does  not  produce  an  eschar.  Cocaine  has  also  a 
haemostatic  action,  and  for  this  purpose  can  be  used  in  operations  on 
the  gums,  in  bleeding  from  the  nose,  etc.  For  the  latter  purpose  cot- 
ton tampons  can  be  used  after  soaking  them  in  a  twenty-  to  thirty-per- 
cent, solution  of  cocaine  (also  adding  a  little  glycerin).  Saint-Germain 
and  Henocque  speak  well  of  the  haemostatic  action  of  antipyi-ine 
(either  in  a  twenty-per-cent.  solution  or  in  the  form  of  a  powder).  In 
cases  of  haemorrhage  from  the  genito-urinary  tract  Meisels  has  made 
successful  use  of  cornutin  (in  doses  of  0*01  gramme  a  day). 

Cold  and  Hot  Irrigation. — We  arrest  capillary  and  parenchymatous 
haemorrhage  by  pressure  applied  for  a  short  tiine,  especially  by  means 
of  aseptic  sponges  or  pads,  by  irrigation  with  ice-water,  or  with  water 


94 


TnE   METHODS  OF   ARRESTING   HEMORRHAGE. 


heated  to  about  45°  C.  (113°  F.),  and  bv  suturing  the  wound  and  ap- 
plying an  antiseptic  dressing  tight  enough  to  exert  pressure.  Ice-water 
stops  the  bleeding  by  causing  the  capillaries  and  smallest  vessels,  to- 
gether with  the  surrounding  tissues,  to  contract,  while  water  at  a  tem- 
perature of  about  45°  C.  (113°  F.)  acts  by  directly  promoting  coagula- 
tion of  the  blood.  This  explains  how  cold  as  well  as  hot  water  has  a 
haemostatic  action.  As  a  rule,  we  employ  antiseptic  solutions  of  a 
medium  temperature  for  irrigation  of  the  wound. 

Suture  of  the  Wound.— An  important  hfemostatic  measure,  as  already 
mentioned,  is  the  exact  coaptation  of  the  edges  of  the  wound  by  means 
of  sutures,  especially  in  the  case  of  parenchymatous  bleeding,  and  in 
hiemorrhage  from  the  smaller  arteries,  particularly  those  of  the  skin. 

Pressure  from  Dressings. — The  application  of  an  antiseptic  dressing 
which  exerts  pressure  likewise  checks  or  prevents  subsequent  paren- 
chymatous oozing. 

Elevation. — In  the  case  of  the  extremities  we  possess  a  valuable 
haemostatic  measure  in  the  form  of  elevation  or  suspension  of  the  part, 
and  in  certain  cases,  particularly  after  the  use  of  Esmarch's  artificial 
ischsemia,  which  is  apt  at  times  to  be  followed  by  se- 
rious parenchymatous  bleeding  or  oozing,  this  pro- 
cedure is  invalual)le. 

Ligature  en  Masse. — When  large  masses  of  tissue  are 
tied  off  at  once  it  is  not  infrequently  found  that  the  liga- 
ture lias  not  been  tied  tight  enough,  and  that,  moreover, 
from  the  manipulation,  the  fingers  become  cracked,  espe- 
cially if  they  come  nuxch  in  contact  with  carbolic  acid; 
and  so  Thiei-sch  has  recommended  that  the  ligature  be 
threaded  through  the  eye  of  a  "  spindle  "  made  of  ivory  or 
nickel-plated  iron  three  to  four  centimetres  long.  The 
point  of  the  spindle  is  rather  blunt,  so  that  it  can  be 
pushed  like  a  probe  through  dense  masses  of  connective 
tissue.  This  method  is  especially  adapted  for  the  ligation 
of  masses  of  tissue  in  ovariotomy,  extirpation  of  the  ute- 
rus, etc.  To  prevent  injury  being  inflicted  upon  the  sur- 
rounding parts  in  these  operations  by  sharp-pointed  nee- 
dles, particularly  in  vaginal  extirpation  of  the  uterus, 
Thiersch  has   constructed  curved,  bhmt-pointed  spindles 

with  an  eye  for  caiTying  the  ligature.     The  spindle  is  held  in  a  forceps  and 

thus  forced  through  the  tissues  (Fig.  80). 


Fig.  80. — Forcep.s  w i th 
a  small  litrature 
hook  for  tying  a 
liirature  en  masse 
(Thiersch). 


Acupressure  and  Acufilopressure. — Acupressure  and  acufilopressure  (Simp- 
son)— that  is,  compression  of  the  vessels  by  long  needles  stuck  through  the 
soft  parts  (acupressure),  or  by  needles  thus  inserted  and  having  a  thread 
wound  around  the  projecting  ends  (acufllopressure)^are  at  present  no  longer 
used  and  will  not  be  described.     Acutorsion  has  also  been  abandoned.     It 


§;J0.]  LKJATION   OK    ARTKllIES    IN   TIIKIR   CONTINUITY.  95 

consisted  in  drjiwinji;'  out  the  divided  extremity  of  tlie  artery  and  transfixinfif 
it  with  a  needle,  whicii  was  then  given  a  half  or  complete  turn  until  the 
bleeding  ceased.     After  some  forty-eight  hours  the  neeiUe  was  removed. 

g  30.  Ligation  of  Arteries  in  Continuity. — The  ligation  of  arteries  in 
tlieir  continuity  is  perionned  lor  injuries  and  for  pathological  condi- 
tions, notably  aneurism.  In  case  of  severe  haemorrhage  from  an 
artery  as  the  result  of  a  punctured,  gunshot,  or  transverse  wound,  it 
used  to  be  the  custom  to  ligate  the  artery  at  its  most  accessible  por- 
tion, in  the  so-called  place  of  election,  proximal  to  the  site  of  injury. 
This  is  not  the  best  plan,  on  account  of  the  frequency  of  secondary 
hiemorrliage  from  the  unsecured  wound  in  the  artery  after  the  collat- 
eral circulation  becomes  established.  At  present  we  search  for  the 
point  where  the  artery  has  been  wounded  and  tie  the  vessel  on  the 
proximal  and  distal  sides  of  the  wound,  and  then  extirpate  the  injured 
portion  of  tlie  vessel  lying  between  the  two  ligatures  and  secure  any 
branches  which  may  be  given  off  in  the  immediate  neighbourhood. 

As  described  under  §  18,  the  ligation  of  arteries  in  their  con- 
tinuity is  performed  as  a  prophylactic  measure,  to  diminish  or  con- 
trol haemorrhage  during  an  operation  upon  the  region  supplied  by  the 
artery  in  question.  Under  this  heading  comes,  for  example,  ligation  of 
the  lingual  arteries  in  extirpation  of  the  tongue,  of  the  femoral  in  dis- 
articulation of  the  femur,  of  the  axillary  or  subclavian  in  disarticula- 
tion of  the  humerus.  Moreover,  the  afferent  arteries  of  a  part  are  some- 
times ligated  to  check  the  growth  of  an  inoperable  tumour,  and  for 
elephantiasis — for  instance,  of  an  extremity,  etc. 

The  operation,  which  is  performed  with  every  aseptic  precaution, 
consists  of  two  parts :  (1)  The  exposure  and  isolation  of  the  artery, 
and  (2)  the  application  of  the  ligature.  In  general  it  is  best  to  use 
Esmarch's  artificial  ischaemia  in  ligating  an  artery  of  an  extremity. 
For  instruments  we  use  a  medium-sized  scalpel,  a  straight  and  curved 
pair  of  scissors,  two  toothed  thumb  forceps,  two  dissecting  forceps, 
several  artery  clamps,  two  retractors,  a  director,  and  an  aneurism 
needle,  with  aseptic  silk  and  catgut  ligatures. 

After  carefully  washing  the  field  of  operation  in  the  usual  way, 
shaving  it,  and  disinfecting  it  with  a  three-per-cent.  solution  of  car- 
bolic acid  or  of  bichloride  1  to  1,000,  and  placing  the  part  in  a 
convenient  position,  an  incision  six  to  eight  centimetres  long  is  made 
through  the  skin  along  the  course  of  the  artery.  The  fingei'S  of  the 
left  hand  hold  the  skin  firmly  stretched,  or  a  fold  of  skin  is  lifted  up 
and  divided  from  without  inwards,  or  transfixed  and  cut  from  within 
outwards.  The  skin  is  divided  by  one  stroke  of  the  knife.  Then  the 
operator  and  his  assistant  seize  the  cellular  tissue  at  two  opposite  points 


96 


THE  METHODS   OF  ARRESTING   HEMORRHAGE. 


with  toothed  forceps,  and  while  it  is  gently  lifted  up  it  is  divided 
between  the  two  forceps  with  the  knife  to  the  full  extent  of  the  cuta- 
neous incision.  The  remaining  tissues  are  divided  as  in  dissecting 
until  the  arterial  sheath  is  reached.  The  sheath 
can  also  be  reached  very  easily  and  quickly  by 
pushing  aside  and  tearing  the  tissues  with  a 
dii-ector,  the  liandle  of  the  knife,  or  the  finger. 
It  is  advisable  for  the  beginner  to  divide  the 
connective  tissue  carefully  upon  the  director. 
When  the  sheath  of  the  artery  has  been  laid 
bare  it  is  well  to  make  certain,  by  palpation 
with  the  finger  tip,  that  it  is  tiie  artery  which 
has  been  exposed.  Even  though  there  be  no 
pulsation,  one  can  easily  distinguish  the  firm, 
thick  arterial  wall  which  can  be  made  to  roll 
under  the  finger  from  the  soft,  thin  wall  of  a 
vein.  A  nerve  feels  like  a  round  solid  cord. 
The    operator  then  grasps  the  sheath    of    the 

Is  »l      J,      artery  with  a  fine-toothed  forceps  or  dissecting 

III  11  foi'ceps,  lifts  it  np  from  the  artery,  and  opens 
^^^  it  with  a  knife  or  Cooper's  scissors  or  a  directoi". 
iTito  the  opening  thus  made  in  the  sheath  of 
the  artery  is  inserted  an  aneurism  needle  or 
curved  blunt  hook  (Fig.  81,  a,  ^),  in  order  to  separate  the  artery  itself 
on  all  sides  from  the  sheath.  One  should  never  free  the  artery  from 
its  sheath  to  too  great  an  extent,  and  one  should  carry  out  this  step 
in  the  operation  as  gently  as  possible,  to  avoid  unnecessary  laceration  of 
the  artery  and  its  sheath.    AVhen  the  entire  circumference  of  the  artery 

has  been  separated  from  its  sheath, 
an  aneurism  needle  bearing  an 
aseptic  catgut  or  silk  ligature  is 
passed  under  the  vessel,  and  after 
encircling  the  latter  the  ligature  is 
tied  fast  around  the  artery  (Fig. 
82).  Two  surgeon's  knots  supple- 
mented by  a  simple  knot  are  usually 
considered  necessary  for  the  larger 
arteries.  A  surgeon's  knot  is  made  by  twisting  the  ends  of  the  liga- 
ture twice  about  each  other,  and  not  once,  as  in  forming  a  simple  knot. 
Large  arteries  are  usuallj'  secured  by  a  doul)le  ligature,  and  the  vessel 
is  then  divided  between  the  central  and  peripheral  ligatures.  If  an 
artery  is  to  be  tied  double — i.  e.,  on  the  central  and  peripheral  side  of 


■rij 


Fio.  81. — Aneurism  needles. 


Fig.  82. — Ligation  of  an  artery  in  its  con- 
tinuity.' 


g30.]  LIGATION    OF   ARTERIES   IN    THEIR  CONTINUITY.  97 

tlic  pt)iiit  of  ill  jury,  porliapf^  a  iMinctiirod  wound — the  aneurism  needle 
is  threaded  with  a  doubled  li<;^atiire,  and  the  latter,  after  bein*^  placed 
around  the  artery,  is  cut  at  the  loop,  thus  giving  one  ligature  for  the 
central  and  the  other  for  the  perii)heral  lii2;ation  of  the  artery.  In 
passing  the  aneurism  needle  around  the  artery  care  must  be  taken  to 
avoid  injury  to  the  neighbouring  vein,  and  before  drawing  the  ligature 
tight  it  must  be  ascertained  that  the  artery  alone  is  tied,  and  that  a 
nerve  is  not  included  in  the  ligature.  After  tying  the  ligature  its 
ends  are  cut  short.  If  the  operation  has  been  performed  with  the  aid 
of  Esmarch's  artificial  ischaemia,  the  rubber  bandage  is  now  carefully 
loosened  and  then  slowly  removed.  When  the  double  ligature  has 
been  tied  and  the  intervening  wounded  portion  of  the  artery  has  been 
extirpated,  the  operator  should  always  look  out  for  branches  arising 
from  this  intervening  portion,  which  should  be  secured  with  the  same 
care  as  the  main  vessel,  because  there  is  a  possibility  of  secondary 
haemorrhage  from  these  branches  after  the  establishment  of  the  collat- 
eral circulation.  The  wound  is  then  drained  from  its  deepest  angle, 
when  this  is  necessary  (see  §  31),  and  closed  throughout  its  whole 
length  with  a  continuous  catgut  suture,  with  or  without  silk  tension 
sutures  (page  106).  An  antiseptic  dressing  exerting  a  gentle  pressure 
must  then  be  applied,  together  with  a  splint  in  the  case  of  the  extremi- 
ties, so  that  the  part  which  has  been  operated  upon  is  immobilised  as 
completely  as  possible.  Immediately  after  the  artery  has  been  ligated 
a  collateral  circulation  takes  place  throngh  the  channels  formed  by 
the  branches  given  off  above  and  below  the  ligature  (see  §  Gl). 

The  ligation  of  particular  arteries  is  taken  up  in  the  text-book  on 
special  surgery. 

The  ligation  of  veins  in  their  continuity  is  carried  out  in  exactly 
the  same  manner  as  described  for  arteries. 

Ligation  of  Large  Veins. — As  a  means  of  checking  haemorrhage  from 
large  veins,  Langenbeck  has  recommended  ligation  of  the  corresponding 
artery.  In  a  case  of  a  wound  of  the  common  femoral  vein  made  during  the 
extirpation  of  a  tumour,  Langenbeck  arrested  the  haemorrhage  by  ligating 
the  femoral  artery.  By  ligation  of  the  corresponding  artery  the  amount  of 
blood  contained  in  the  part  of  the  body  which  it  supplies  is  so  diminished 
that  the  wound  in  the  vein  is  able  to  close  spontaneously.  A  simple  dress- 
ing exerting  slight  pressm'e  is  then  sufficient  to  stop  the  bleeding.  But  in 
other  cases  the  method  has  entirely  failed.  It  is  always  safer,  when  possible, 
to  secure  the  wounded  vein  itself. 

V 


CHAPTER   YII. 

DRAINAGE    OF    WOUNDS. 

Importance  of  drainage. — Different  methods  of  draining  a  wound  :  leaving  the  wound 
open  ;  aseptic  packing  ;  drainage  by  rubber  tubes. — Absorbable  drains. — Drainage 
tubes  of  glass,  metal,  etc. — Capillary  drainage  with  strands  of  catgut,  horse-hair, 
and  glass  wool. — Formation  of  openings  in  the  skin. — Secondary  suture  of  Kochei'. 
— Healing  under  a  blood-clot  without  drainage  (Schede). 

§  31.  The  Method  of  allowing  the  Secretions  of  a  "Wound  to  Escape. — 
Drainage. — In  every  fresh  wound  there  is  regularly  an  escape  of  a 
hloody,  serous  fluid,  rich  in  albumin,  from  the  divided  tissues,  the  open 
capillaries,  and  lymph  spaces,  and  it  corresponds  in  amount  with  the 
size  of  the  wound  and  the  number  of  cavities  and  pockets.  The  forma- 
tion of  these  cavities  in  the  wound  should  be  prevented,  as  far  as  possi- 
ble, by  sutures  and  by  the  application  of  a  dressing  exerting  proper 
pressure.  By  means  of  the  latter  we  try  to  promote  the  agglutination 
of  the  more  deeply  lying  tissues  which  have  been  divided,  and  thus  to 
diminish  the  ensuing  secretion — a  matter  of  much  importance.  In 
small  wounds  the  pressure  exerted  by  the  dressings  is  sufficient  to 
obtain  rapid  healing,  and  it  is  not  necessary  to  use  means  for  car- 
rying off  the  secretion  except  when  suppuration  is  already  present, 
and  in  the  case  of  large  fresh  wounds.  But  if  suppuration  is  present, 
we  must  provide  suitable  channels  for  the  escape  of  the  secretion  in 
the  shape  of  drainage  in  some  form.  Unless  we  do  this  the  secretion 
is  retained  in  the  wound  and  prevents  primary  union.  Moreover, 
opportunity  is  given  for  the  secretion  to  decompose  and  for  pus  to 
form,  and,  as  a  result  of  the  retention  of  the  pus  or  decomposed  secre- 
tion of  the  wound,  spreading  suppurative  inflammation  or  general 
infection  of  the  whole  system  takes  place  from  absorption  of  the  infec- 
tious material  (pygemia,  septicaemia).  The  bloody,  serous  secretion 
present  in  the  wound,  and  the  blood  which  has  escaped,  are  highly 
decomposable,  on  account  of  their  albuminous  character,  and  conse- 
quently it  is  a  matter  of  great  importance  to  provide  careful  drainage 
in  large  clean  wounds  and  particularly  in  those  which  are  already 
infected.     At  the  present  time  attempts  have  been  made  to  do  away 

(98) 


45^1. j      MKTIIOI)  UK  ALI.OWIXC   WOUND  SKUliHTIUNS  TO  KSCAPI].         (j<j 

with  (lniinaii:;e  in  woiiiuls  made  in  aseptic  operations,  hut  most  snr<^eons 
still  ivly  upon  it.  As  a  matter  of  fact,  it  is  indispensahle  for  the  first 
twenty-four  to  f(.)rty-oii;ht  hours  in  large  aseptic  wounds,  even  after 
they  have  been  closed  by  sutures — for  example,  after  amputation  of 
the  breast,  accompanied  by  cleaning  out  the  axilla.  The  secretion  from 
the  wound  and  the  effused  blood  can  thus  escape,  and  so  do  not  pre- 
vent the  edges  of  the  wound  from  quickly  uniting  by  primary  inten- 
tion. There  are  various  methods  for  enabling  the  secretion  from  the 
wound  to  escape. 

The  simplest  of  these  is  to  leave  the  wound  open  without  suturing 
it,  or  only  partially  suturing  it,  leaving  the  angles  of  the  wound  un- 
closed. We  combine  with  this  open  treatment  the  sprinkling  of  the 
wound  with  antiseptic  powders  (iodoform,  boric  acid,  salicylic  acid, 
etc.),  or  we  fill  deep  wounds  or  cavities  with  dressing  materials  which 
have  a  greater  or  less  absorptive  power — for  examjile,  with  strips  or 
wads  of  iodoform  gauze.  This  aseptic  packing  of  a  wound  is  an  excel- 
lent method  of  drainage,  as  it  absorbs  the  secretion  from  the  wound 
and  causes  it  to  reiliain  aseptic.  When  necessary,  the  packing  can  be 
fastened  in  place  by  sutures  through  the  skin.  Abounds  which  have 
been  left  open  can  then,  after  a  few  days,  when  the  packing  is  removed, 
be  closed  by  secondary  suture,  as  it  is  called,  which  hastens  the  healing 
process.  Gliick  has  recommended  the  use  of  an  absorbable  aseptic 
packing,  consisting  of  rigorously  disinfected  sponges  impregnated  with 
iodoform,  or  a  mixture  of  iodoform,  ether,  and  alcohol,  and  also  skeins 
or  rolls  of  catgut,  and  bundles  of  silk  w4th  or  without  catgut  of  differ- 
ent shapes  and  sizes.  He  recommends  their  use  particularly  for  intra- 
peritoneal drainage.  Catgut  alone  is  absorbable,  and  therefore  only 
this  material  can  be  used  as  an  absorbable  packing.  Tlie  absorbable 
aseptic  packing  becomes  encapsulated,  granulation  tissue  grows  into  it, 
and  its  place  is  gradually  taken  by  connective  tissue.  I  do  not  con- 
sider this  method  desirable. 

If  we  wish  to  immediately  close  large  and  deep  wounds,  which  have 
not  been  infected,  so  as  to  obtain  rapid  healing  with  primary  union — 
i.  e.,  direct  agglutination  of  the  tissues  without  the  formation  of  pus, 
as  in  amputations,  resection  of  joints,  extirpation  of  tumours,  etc. — we 
take  proper  steps  for  conducting  off  the  secretions  of  the  wound  by 
drains  inserted  into  the  deepest  portions  of  the  wound. 

Drainage  Tubes. — The  ordinary  drains  are  made  of  tubes  of  vulcan- 
ised rubber,  provided  with  numerous  lateral  openings  (Fig.  83).  These 
rubber  drainage  tubes  should  have  as  large  a  calibre  as  possible,  and, 
while  not  being  too  long,  they  must  alwa^^s  be  so  inserted  as  to  render 
easy  the  escape  of  the  secretions  from  any  part  of  the  wound,  and 


100 


DRAINAGE  OF  WOUNDS. 


Fio.  85. —  Drain 
forceps. 


therefore  should  reach  into  its  deepest  portions.  Whenever  possible,  I 
place  the  drain  to  one  side  of  the  suture  line  and  not  directly  beneath  it, 
so  as  not  to  separate  the  suture  line  from  the  underlying  parts  and  thus 
render  it  impossible  for  primary  union  to  take  place.     Drains  are  passed 

through  a  wound  with  the  aid  of  dress- 
ing forceps  (Fig.  85)  after  the  skin  has 
been  first  incised  with  a  knife  and  the 
remaining  soft  parts  have  been  pierced 
by  the  forceps.  The  drainage  tube  is 
secured  in  its  position  by  a  stitch  tak- 
ing in  a  part  of  tlie  end  of  the  tube, 
or  by  a  disinfected  safety  pin,  and 
thus  prevented  from  slipping  into  the 
wound.  The  drain  is  removed  from 
fresh  wounds  at  the  same  time  that 
the  stitches  are,  or  by  the  second,  third, 
fourth,  or  seventh  day,  according  to 
the  nature  of  the  case  and  the  size  of 
the  wound.  If  it  is  a  suppurating 
wound  the  drain  is  taken  out  when 
the  suppuration  ceases,  and  under  such 
conditions  it  is  best  not  to  remove  the  drainage  altogether  at  one  time, 
but  first  to  shorten  the  tubes  and  then  gradually  take  them  out. 

I  have  recommended  short  drainage  tubes  of  large  calibre  because 
they  do  not  so  easily  become  plugged  up,  and  consequently  there  is  no 
necessity  for  syringing  them  out  with  antiseptic  solutions.  This  syring- 
ing out  of  drainage  tubes  should  be  avoided,  especially  in  all  fresh 
wounds  produced  in  an  operation.  It  can  only  do  harm  by  irritating 
tlie  wound  and  forcing  apart  again  the  already  adherent  wound  surfaces. 
Even  washing  out  a  suppurating  wound  with  antiseptic  solutions  by 
means  of  an  irrigator  (Fig.  86)  is  often  entirely  unnecessary,  and  may, 
indeed,  do  harm. 

Absorbable  Drainage  Tubes. — Besides  rubber  drainage  tubes,  other 
forms  have  been  used,  such  as  absorbal)le  tul)es  made  of  decalcified 
bone  (Trendelenburg,  Neuber),  glass  tubes  (Fig.  84),  silver  tubes,  tubes 
made  from  a  coil  of  wire,  etc.  The  absorbable  drainage  tubes  of  decal- 
cified bone  liave  not  come  into  very  general  use,  because  they  are  liable 
to  be  absorbed  too  quickly  before  they  have  accomplished  their  pur- 
pose. 

Preparation  of  Absorbable  Bone  Drains.— Absorbable  bone  drainage  tubes 
are  made  as  follows:  The  long,  hollow  bones  of  fowls  and  other  birds  are 
freed  from  soft  parts  by  boiling,  and  then  placed  for  about  ten  or  twelve 


t^Sl.]      METHOD  OF  ALLOWING  WOUND  SKCRpynONS  TO  ESCAPE.     101 

hours  in  a  mixture  of  one  part  of  hydrochloi-ic  iicid  tind  two  parts  of  water; 
the  ends  of  the  bones  are  cut  otf  with  scissors  and  their  interior  cleaned  out 
with  a  stout  wire,  after  which  they  are  boiled  in  a  flve-per-cent.  carbolic 
solution,  to  which  Deakin  adds  some  borax,  and  they  are  finally  stored  foi- 
use  in  the  same  solution. 

Hardeningof  Rubber  Drains.— To  prevent  rubber  tubes. from  becoming- 
.soft,  it  is  a  <i(K)d  plan  to  harden  tliem  by  placing  them  in  coucentrated  sul- 
phuric acid  for  about  five  minutes,  the  larger  sizes  a  little  longer;  then  wash 
the  tubes  in  seventy-five-per-cent.  alcohol  and  store  them  in  a  five-per-cent. 
carbolic  solution  or  in  a  1  to  2  to  1,000  bichloride  solution.  The  orange-red 
colored  rubber  tubes  are  the  best  adapted  to  tiiis  process,  the  gray  and  black 
not  being  so  good.  After  the  rubber  tubes  have  once  been  hardened  this 
quality  remains  unchanged  by  the  fluid  in  which  they  are  kept  stored. 

Strands  of  Catgut  as  a  Drain. — The  smallest  drain  which  we  use  con- 
sists of  strands  of  aseptic  catgut  or  horse-hair,  which  are  laid  side  by 
side  in  the  form  of  a  bundle  of  threads.  This  bundle,  for  example,  of 
catgut  is  pushed  through  a  small  perforation  in  the  skin,  or  through 
the  open  extremity  of  the  suture  line,  down  into  the  wound,  thus  sup- 
plying, in  small  wounds,  an  excellent  form  of  capillary  drainage. 
Kummel  has  recommended  capillary  glass  drainage  in  the  form  of 
strands  of  spun  glass. 

Attempts  have  been  made  to  substitute  drainage  by  means  of  holes 
made  in  the  skin  for  the  ordinary  drainage  with  rubber  tubes  in  case  of 
wounds  directly  under  the  skin,  and  the  canalisation  of  skin  and  mus- 
cular tissue  in  case  of  deeper  w^ounds  (Esmarch  and  Keuber).  To  make 
a  canal  of  skin  and  muscular  tissue  for  purposes  of  drainage,  the  cut 
edge  of  the  skin  on  each  side  is  attached  by  a  catgut  suture  to  the 
wound  in  the  muscular  tissue  beneath  it. 

Of  all  these  different  kinds  of  drainage,  in  my  judgment  the  ordi- 
nary drainage  supplied  by  rubber  or  glass  tubes,  or  by  packing  the 
wound  with  sterilised  gauze,  is  by  far  the  best,  and  all  other  methods 
(strands  of  catgut,  bundles  of  horse-hair,  cutaneous  punctures,  canalisa- 
tion, and  absorbable  drains)  are  only  suitable  for  small  wounds,  and  are 
insufficient  for  large,  deep  wounds  in  which  there  are  pockets.  If  the 
drainage  by  rubber  tubes  is  properly  managed  and  the  drains  removed 
at  the  right  time,  it  is  easy  to  prevent  the  evil  consequences  which  the 
tubes  sometimes  cause,  such  as  necrosis  of  the  skin,  persistent  fistulae, 
etc.  If  an  operation  is  performed  in  a  rigorously  aseptic  manner,  with 
carefully  sterilised  instruments  and  hands,  and  without  leaving  diseased 
tissues  in  the  wound,  often  large  wounds  made  during  the  operation 
may  be  closed  without  drainage.  When  this  is  done  it  is  best  to  main- 
tain moderate  pressure  upon  the  wound  by  means  of  the  aseptic  dress- 
ing.    It  is  exceedingly  important  that  the  wound  should  be  irritated  as 


102  DRAINAGE   OF    WOUNDS. 

little  as  possible,  and  hence  antiseptic  solutions  should  only  be  used 
wlien  absolutely  necessary, 

Kocher's  Substitute  for  Drainage.— Kocher  has  tried  to  dispense  with 
the  drainage  of  tlie  wound  by  covering  it  with  a  thin  layer  of  subnitrate  of 
bismuth.  The  latter  is  sprinkled  over  the  wound  in  the  form  of  a  one-per- 
cent, mixture  of  bismuth  in  water,  which  is  di'opped  out  of  a  flask  ;  or,  if 
there  is  bleeding,  compresses  impregnated  with  bismuth  are  applied  to  the 
wound.  The  wound  surface  is  so  much  di'ied  up  by  tlie  bismuth  that  the 
secretion  is  almost  nil.  After  twelve,  twenty-four,  or  forty-eight  houi-s  the 
wound  is  closed  by  secondary  suture. 

Schede's  Method  of  healing  under  a  Blood-Clot— Schede  has  recently 
recommended  "healing  under  a  moist  blood-clot" — e.  g.,  he  permits  a  cavity 
which  has  been  hollowed  out  of  a  bone  to  fill  with  blood,  closing  the  wound 
tiglit  by  suturing  the  skin  and  not  insei'ting  any  drain.  If  the  coagulum 
thus  formed  in  the  course  of  an  aseptic  operation  remains  a.septic,  it  will  be 
gradually  absorbed  and  its  place  taken  by  newly  formed  connective  tissue  or 
bone,  and  healing  will  occur  without  reaction.  I  think  tbis  method  deserves 
a  fair  trial  ;  it  has  proved  of  service  to  me  after  operations  for  caries  and 
necrosis.  To  prevent  the  coagulum  from  becoming  too  large,  I  leave  the 
lower  angle  of  the  cutaneous  wound  open.  The  whole  point  in  Schede's 
method  is  the  doing  away  with  the  drains.  As  Lauenstein  has  correctly 
pointed  out,  this  method  is  particularly  suitable  for  all  wounds  with  loss  of 
substance  in  bones  and  soft  parts,  but  it  is  not  suitable  for  wounds  in  which 
the  wound  surfaces  can  be  brought  into  apposition  by  primary  or  secondary 
sutures.  Bad  results  are  chiefly  due  to  iniperfect  asepsis  during  the  0])era- 
tion  or  after  treatment. 


CIIAPTEK   VITI. 


THE    METHOD    OF    IXITIXG    THE    TISSUES. SUTURE    OF    THE    WOUND. 

Disinfection  of  the  wound  and  surrounding  parts  before  inserting  the  sutures. — Suture 
of  the  soft  parts. — Needles,  needle-holders,  and  suture  materials. — Different  meth- 
ods of  suturing  the  wound  (interrupted,  continuous,  silver-wire  suture,  plate 
suture,  twisted  suture). — Removal  of  the  sutures. — Secondary  suture. — Bloodless 
suture. — Subcutaneous  suture  of  nerves,  tendons,  muscles,  etc. — Union  of  wound 
surfaces  in  bones  (bone  suture). — Periosteal  suture. — Nailing  and  other  methods  of 
uniting  the  surfaces  of  a  divided  bone. 

§  32.  Disinfection  of  the  Wound  before  inserting  the  Sutures.— After 
arresting  the  hsemorrliage  very  carefully  and  putting  in  the  proper  drain- 
age, the  wound  and  the  surrounding  parts  are  waslied  with  a  three- 
per-cent.  solution  of  carbolic  acid  or  1  to  1,000-5,000  solution  of 
bichloride  of  mercury.  The  irrigator  (Fig.  86)  is  best  suited  for  this 
purpose  ;  it  is  made  of  metal — or,  better,  of  glass — with  a  rubber  tube 
provided  with  a  removable  tip 
made  of  glass  or  rub1)er,  througli 
which  the  solution  flows.  A 
warning  must  be  given  against 
too  vigorous  cleansing  of  the 
wound  with  antiseptics — ex- 
cepting in  the  case  of  already 
infected  wounds — because  too 
much  irritation  is  produced, 
and  the  ensuing  secretion  from 
the  wound  will  be  increased.  I 
irrigate  wounds  made  during 
an  operation  only  in  those  cases 

"in  which  there  is  the  possibility  of  infection  having  occurred  during  the 
operation.  In  wounds  already  infected  and  when  pus  is  present,  etc., 
fairly  strong  antiseptic  solutions  should  be  employed  (four-to-five-per- 
cent, carbolic  or  1  to  1,000  bichloride),  but  the  weaker  antiseptic  solu- 
tions should  be  used  at  the  end  to  again  remove  from  the  w^ound  the 
concentrated  and  more  or  less  caustic  solutions  which  may  easily  produce 
symptoms  of  poisoning.     If  there  are  no  irrigators  at  hand,.clean,  well- 

(103) 


Irrigator. 


104 


THE  METHOD   OF    UNITING  THE  TISSUES. 


disinfected  sponges,  or  aseptic  gauze,  or  cotton  tampons,  may  be  soaked 
full  of  the  antiseptic  fluid,  which  is  then  squeezed  out  over  the  wound 
and  adjoining  parts,  thus  cleansing  them.  I  use  antiseptic  solutions  as 
little  as  possible,  and  avoid  irrigating  the  wound  with  them  after  the 
operation,  as  the  secretion  from  the  wound  is  much  less  if  the  irriga- 
tion with  irritant  solutions  is  omitted.  The  main  point  is  always  to 
operate  with  perfectly  aseptic  hands  and  instruments.  "When  the 
haemorrhage  has  been  arrested  and  the  wound  treated  on  these  general 
principles,  we  proceed  to  insert  the  sutures. 

§  33.  The  Uniting  of  the  Soft  Parts — Suture  of  the  Wound. —  In  all 
cases  in  which  we  wish  to  obtain  as  speedy  union  of  the  wound  as  pos- 
sible {^per  J) r imam  inteationeni)  we  close  the  wound  by  suturing  to- 
gether its  edges.  Suturing  should  always  be  carried  out  with  the  same 
regard  to  asepsis  as  was  had  in  the  operation  itself,  and  hence  the 
needles  and  the  sutures  must  be  previously  made  aseptic. 

For  introducing  sutures  we  use  straight  and  variously  curved  nee- 
dles with  lance-shaped  points.  I  use  straight  lance-shaped  needles 
almost  exclusively  for  the  skin.  Curved  needles  are  suited  particularly 
for  deeply  lying  portions  of  the  body  and  for  introducing  sutures  in 


Fig.  87. — Needle  holders. 

cavities  (mouth,  gums,  throat,  vagina,  etc.).  Hagedorn's  needles,  which 
are  flattened  on  the  sides,  are  very  useful.  The  recently  introduced 
platinum-iris  needles  possess  the  advantage  of  not  oxidising,  and  they 
can  be  heated  red-hot  without  losing  their  original  temper.  Besides 
the  ordinarv  needles  without  handles,  there  are  many  provided  with 


fc5;«.J  THE   UNITING    OF  THE   SOFT   PARTS.  105 

liandles,  tliouijh  I  never  use  thoin.  AVhen  tlie  needle  cannot  be  intro- 
duced by  hand,  as  in  the  mouth  or  pharynx,  tlie  vaii:ina,  etc.,  we  use  a 
needle-liolder.  Of  the  numerous  different  kinds  of  needle-holders,  those 
worthy  of  mention  are  the  holders  of  Dieffenbach,  Reiner  (Kig.  87,  a), 
Koux  (Fig.  87,  b),  and  Sims  (Fig.  87,  c).  llagedorn  has  recently  in- 
vented a  most  excellent  needle-holder,  which  I  now  use  exclusively 
(Fig.  87,  (I). 

Suture  Material — Sutures  are  made  of  sterilised  silk  impregnated 
with  carbolic  acid  or  bichloride  of  mercury,  of  linen  thread,  catgut, 
horse-hair,  sea-grass,  silkworm  gut  (from  the  chrysalis  of  the  silkworm), 
crin  de  Florence  (from  the  intestine  of  the  silkworm),  and  silver  wire. 
Catgut  has  the  great  advantage  over  silk  that  it  is  absorbable,  and  is 
therefore  preferable  for  subcutaneous  or  buried  sutures — that  is,  suture 
of  nerves,  tendons,  muscles,  etc.  Moreover,  buried  catgut  sutures  are 
the  best  for  uniting  a  ruptured  perinseum  ;  for  the  radical  cure  of  her- 
nia ;  for  operations  on  the  uterus,  bladder,  or  intestine ;  and  for  opera- 
tions on  fistulfe.  If  catgut  is  used  for  suturing  the  skin,  the  sutures 
will  not  need  to  be  removed  with  scissors,  but  after  about  four  to  seven 
days  the  external  portion  lying  over  the  line  of  the  wound  can  be  sim- 
ply picked  off  with  forceps,  as  the  part  which  lies  buried  in  the  tissues 
is  al)sorbed,  or  is  only  very  weakly  attached  to  the  rest  of  the  suture. 
On  account  of  this  rapid  absorption  of  catgut,  it  follows  that  under 
certain  conditions  catgut  sutures  will  not  hold  the  borders  of  the 
wound  long  enough  in  apposition,  and  so  I  do  not  use  catgut  alone  for 
suturing  the  skin,  but  combine  it  with  aseptic  silk,  especially  if  the 
skin  is  under  considerable  tension.  The  preparation  of  a  satisfactory 
catgut  has  been  described  on  page  88.  The  size  of  the  catgut  or  silk 
suture  required  will,  of  course,  depend  upon  the  kind  of  tissues  to  be 
united  and  the  amount  of  tension.  AVhen  there  is  great  tension  strong 
sutures  are  naturally  required,  because  fine  sutures  would  easily  cut 
through. 

Silver  wire  should  be  made  smooth  before  use  by  passing  it 
through  a  flame  till  it  becomes  red-hot.  Silkworm  gut  is  excellent 
for  tying  off  the  pedicle  in  ovariotomy,  for  perineal  operations,  etc. 
In  the  place  of  expensive  silk,  Trendelenburg  and  Heyder  recommend 
linen  thread  for  ligatures  and  sutures.  It  is  cheap,  and  easily  obtained 
at  any  time  (even  in  war). 

Sutures  made  from  the  Tendons  of  Reindeer,  Horses,  and  Deer.— Ratiloff 
uses  the  tendons  of  reindeer  for  suturing  wounds.  This  material  Is  used  by 
tlie  Siberian  colonists  for  sewing.  Putilow  uses  the  tendons  of  horses  and 
deer.  The  strips  of  tendon  are  soaked  for  twenty-four  hours  in  ether,  and 
for  the  same  length  of  time  in  a  tive-per-cent.  alcoholic  solution  of  carbolic 


106 


THE   METHOD   OF   UNITING   THE  TISSUES. 


acid.    The  strips  of  tendon  thus  prepared  are  said  to  be  stronger  than  catgut, 
as  soft  as  silk,  and  completely  absorbed  in  the  wound. 

The  Interrupted  Suture. — The  most  common  form  of  suture  is  tlie 
so-called  interrupted  suture  (Fig.  88).  This  is  introduced  with  straiglit 
or  curved  needles,  the  aseptic  catgut  or  silk  being  simply  knotted  in 
the  eye  of  the  needle,  or,  better,  threaded  so  as  to  leave  two  long  ends. 
The  knot,  especially  if  the  suture  is  of  large  size,  interferes  with  draw- 
ing the  eye  portion  of  the  needle  through  the  skin.  The  border  of 
the  wound  is  seized  with  a  toothed  forceps,  and  the  needle  is  pushed 
throuorh  first  one  edsre  of  the  wound  and  then  the  other.  Both  edges 
of  the  wound  can  be  pierced  at  the  same  time,  provided  they  are  held 
together  by  an  assistant.  The  knots  should  be  placed  to  one  side  of 
the  line  of  suture.  If  there  is  much  tension  on  the  edges  of  the  wound 
the  so-called  surgeon's  knot  is  occasionally  used — that  is,  the  ends  of 
the  suture  are  twisted  not  once,  but  twice  about  each  other.  It  is  best 
to  begin  the  suture  not  at  the  ends  of  the  wound, 
but  in  the  middle,  especially  if  it  is  a  long  one ;  and 
at  the  time  of  inserting  the  first  suture  care  should 
be  taken  to  have  the  borders  of  the  wound  in  good 
apposition,  as  otherwise  troublesome  folds  at  the  ex- 
tremities of  the  line  of  suture  may  result. 

Two  different  kinds  of  sutures  are  classed  under 
the  head  of  interrupted  sutures — the  tension  suture 
and  the  coaptation  suture.  The  first  is  inserted  and 
brought  out  anywhere  from  1-2  to  4-6  centimetres 
from  the  edges  of  the  wound,  whilst  tlie  second  or 
coajnation  suture  is  shorter,  and  the  points  where  it 
enters  and  emerges  are  only  about  half  a  centimetre 
distant  from  the  edges  of  the  wound  (Fig.  88). 

Those  sutures  by  which  correct  apposition  of  the  borders  of  a  long 
wound  are  obtained  are  called  apposition  sutures.  In  every  suture  line 
the  greatest  care  is  necessary  to  prevent  the  edges  of  the  wound  from 
becoming  inverted,  and  the  two  borders  must  lie  in  good  apposition 
with  each  other.  The  sutures  must  not  be  drawn  too  tight.  It  must 
constantly  be  borne  in  mind  that  the  successful  healing  of  a  sutured 
wound  depends  upon  the  proper  insertion  of  the  sutures,  and  that 
sutures  applied  unskilfulh'  and  without  antiseptic  precautions  may 
give  rise  to  serious  dangers.  An  erysipelas  which  may  cause  the  death 
of  the  patient  may  start  from  a  small  spot  of  necrosis  in  the  skin,  aris- 
ing, perhaps,  from  a  portion  of  the  border  of  the  wound  which  has  got 
turned  in,  if  the  borders  of  the  wound  are  not  properly  placed  in  appo- 
sition ;    or  it  may  start  from  a  small  stitch  abscess  produced  by  an 


Fig.  88. — luterrupteJ 
suture. 


§33.] 


THE    UNITING   OF   THE  SOFT   PARTS. 


107 


a>r^. 


imperfectly  disinfected  needle  or  suture.  Tremendous  results  may 
follow  from  very  small  causes.  Furthermore,  no  a]j})reciable  cavity 
should  be  allowed  to  remain  ;  and  hence  the  deeper-lying  parts  are 
sometimes  united  by  special  catgut  sutures  or  are  included  in  the  cuta- 
neous sutures.  "  Good  sutures,  good  results,"  was  a  favourite  saying 
of  Nussbaum. 

Continuous  Suture. — Instead  of  the  ordinary  interrupted  suture  I 
frequently  use  the  continuous  suture,  and  usually  in  combination  with 
tension  sutures  (Fig.  89).  I  use,  whenever  it  is  possible,  needles  with 
lance-shaped  points,  of  the  same  size  as  the  ordinary  tailors'  needles. 
The  fine  suture,  which  should 
not  be  too  long,  is  simj)ly 
knotted  in  the  eye  of  the 
needje.  The  number  of  ten- 
sion sutures  required  depends, 
of  course,  upon  the  length  of 
the  wound.  The  tension  su- 
tures are  inserted  in  the  usual 
way,  and  then  the  continuous 
suture  is  begun  at  one  end  of 
the  wound  by  making  one 
ordinary  interrupted  suture ; 
the  thread,  however,  is  not  cut, 

but  the  suture  is  continued  by  transfixing  at  equal  distances  the  opposed 
borders  of  the  wound,  which  are  held  together  by  the  fingers.  When 
the  other  end  of  the  wound  is  reached  (Fig.  89,  a)  the  suture  is  cut  with 
scissors,  and  the  three  threads  are  knotted  together  like  the  ordinary 
interrupted  suture,  two  threads  being  on  one  side  of  the  w^ound  and 
one  upon  the  other.  The  suture  can  also  be  finished  off  by  forming 
a  loop  through  which  the  extremity  of  the  suture  is  drawn.  The  con- 
tinuous suture  has  the  advantage  over  every  other  kind  of  being  capable 
of  very  rapid  execution,  and  of  rendering  excellent  coaptation  of  the 
borders  of  the  wound.  If  the  wound  is  very  long  and  there  is  fear  that 
a  single  continuous  suture  will  not  be  strong  enough,  the  suture  can  be 
interrupted  at  any  desired  part  of  the  wound,  and  from  this  point  a  fresh 
continuous  suture  can  be  begun  ;  or  it  can  be  given  greater  security  by 
tying  it  at  any  point  and  then  continuing.  But  when  the  precaution  of 
inserting  tension  sutures  is  taken  there  need  be  no  fear  that  the  continu- 
ous suture  will  prove  at  all  untrustworthy  if  it  is  carefully  inserted. 
Catgut  is  ordinarily  the  best  material  for  the  continuous  suture,  and  I 
use  aseptic  silk  for  the  tension  sutures.  The  continuous  suture  is  par- 
ticularly adapted  for  operations  on  the  peritonaeum  and  the  gastro- 


FiG.  89.--Continuous  suture. 


108 


THE   METHOD   OP   UNITING   THE  TISSUES. 


Fig.  yO. 

Wire    su 

ture  tight 

I'uer. 


intestinal  tract,  and  for  tlie  buried  catgut  suture  in  operations  on  the 
vaiiina  for  prolapse  and  for  rupture  of  the  perinsenm. 

Silver-wire  Sutures. — If  silver  wire  is  used  for  suturing,  it  is  fast- 
ened to  a  straight  or  curved  needle  by  simply  bending  over  one  end  of 
the  wire  after  it  is  tlireaded  through  the  eye.  The  silver-wire  suture 
is  fastened  in  place  by  exerting  suitable  traction  on  the  wire  and  then 
simply  twisting  together  its  crossed  ends,  or  an  instrument  particularly 

designed  for  the  purpose  may  be  used  (Fig- 
90),  The  cross-piece  of  the  "  wire  twister  " 
contains  two  round  openings  into  which  the 
i;^  y  ill  ends  of  the  w^ire  are  passed  after  they  have 
been  crossed  over  the  wound,  and  then  by 
rotating  the  instrument  the  wires  are  twisted 
around  each  other. 

The  Silver-wire  Suture  with  the  Lead  Plate. 

— A  form  of  tension  suture  which  has  at  present 
somewhat  gone  out  of  use  is  the  silver-wire  lead- 
^  plate  suture  used  for  closing  the  wound  after 

Fig.  91.  abdominal  section  or  amputation  of  the  breast. 

Lead  plates.  Small  lead  or  glass  plates  are  required  which 

are  perforated  in  the  centre.  The  silver  wire  is 
either  twisted  around  the  plate  (as  in  Fig.  91, 
a),  or  fastened  to  pins  on  its  surface  (Fig.  91,  6),  or  else  the  silver  wire  is 
inserted  in  a  small  lead  ring  which  is  pinched  together  with  forceps.  Glass 
beads  can  also  he  used.  The  end  of  the  wire  is  passed  twice  through  the 
bead  and  drawn  tight,  then  through  the  lead  plate,  and  after  attaching  it  to 
a  needle  the  suture  is  inserted.  Upon  the  other  side  of  the  wound  the  wire 
is  first  passed  through  the  lead  plate,  then  through  one  or  more  glass  beads, 
and  after  obtaining  the  proper  tension  the  wire  is  twisted  around  a  sterilised 
match  and  the  ends  are  cut  short  with  scissors.  It  is  a  very  good  plan  to  use, 
instead  of  silver  wii'e,  a  double  silk  suture  having  each  end  so  fastened 
together  over  a  glass  bead  that  only  one  and  not  both  threads  pass  through 
the  bead.  Pledgets  of  iodoform  gauze  can  also  be  used  for  securing  the  ends 
of  the  silver-wii'e  lead-plate  suture.  At  present  I  have  given  up  this  kind 
of  suture,  aud  prefer  a  tension  sutui-e  of  stout  sterilised  silk  insei'ted  some 
distance  from  the  edge  of  the  wound.  The  latter,  furthermore,  is  more  quickly 
inserted. 

Other  Methods  of  Suturing.— Tlie  old  fashioned  continuous  furrier's  stitch, 
the  fin  stitch,  and  the  looped  suture  are  useless  and  out  of  date,  and  will  not 
be  described.  The  continuous  suture  which  I  have  described  differs  materi- 
ally from  the  continuous  furrier's  stitch.  The  so-called  "  figure-of-8 "  or 
twisted  suture  (Fig.  92)  I  also  consider  unnecessary,  and  no  longer  use  it. 
The  interrupted  suture  answers  the  same  purpose,  and  is  more  simply  in- 
serted and  is  better  for  the  tissues.  It  is  applied  in  the  following  way:  The 
edges  of  the  wound  are  transfixed  by  long  Carlsbad  needles  some  distance 
apart.     About  the  ends  of  the  needles  is  twisted  an  aseptic  silk  suture  in  the 


g33.J  THE   UNITING    OF  THE  SOFT   PARTS.  IO9 

form  of  a  circle  or  fi<?uro  of  S,  aiul  the  exireinitios  of  tlic  tliroad  are  knotted 
together.  The  sliarp  ends  of  tlie  ueeille  are  clii)pi!d  off  with  a  Liier's  rongeur 
force])s. 

Deep  Sutures  attached  to  Beads.— Tliierseh's  method  of  inserting  deep 
sutures  with  their  ends  attached  to  beads — for  example,  into  the  rectum  or 
vagina — is  a  very 
good  one.  To  the 
end  of  the  silver  wire 
ahead  is  fastened,  as 
in  the  plate  suture: 
a  lead  plate  is  then 
placed   next  on  the 

wire,  the  other  end  Fig.  92.— Figure-of-S  suture. 

of  which  is  threaded 

on  a  needle  and  passed  through  the  borders  of  the  wound.  After  removing 
the  needle,  the  needle  end  of  the  wii-e  is  passed  through  ten  to  twenty  glass 
beads  and  secured  by  pinching  together  a  piece  of  lead  upon  it;  by  pushing 
the  lead  up  or  down  on  the  beads  the  suture  can  be  loosened  or  tightened. 
To  remove  the  suture,  the  wire  is  cut  on  the  proximal  side  of  the  piece  of  lead 
and  pulled  out  by  drawing  on  the  other  end. 

The  Removal  of  Sutures. — The  stitches  are  taken  out,  in  the  majority 
of  cases,  at  any  time  from  the  third  to  tlie  seventli  day,  according  to  the 
kind  of  wound.  AVe  frequently — for  instance,  after  plastic  operations 
on  the  face — take  out  a  stitch  here  and  there  at  the  end  of  twenty-four 
liours ;  but  in  other  cases,  on  the  contrary,  as  when  the  peritoneal  cav- 
ity lias  been  opened,  we  allow  the  stitches  to  remain  till  the  eighth  to 
the  fourteenth  day.  In  long  wounds,  and  in  those  in  which  there  is 
danger  of  the  agglutinated  bordei-s  of  the  wound  separating  after 
removal  of  the  sutures,  the  latter  should  not  all  be  taken  out  at  the 
same  time.  The  tension  sutures,  particularly  at  the  extremities  of  the 
wound,  when  combined  with  the  continuous  suture,  should  be  taken 
out  first.  If  the  tension  sutures  become  buried  in  the  skin — i.  e.,  "  cut 
otit " — they  should  be  removed  immediately.  Sutures  are  removed  by 
seizing  one  end  of  the  knot  with  dissecting  forceps  and,  while  slight 
traction  is  exerted,  cutting  off  the  suture  close  to  the  wound  and  care- 
fully drawing  it  out.  Care  must  be  taken  that  the  whole  suture  is 
removed.  If  catgut  has  been  used  it  is  unnecessary  to  cut  the  stitches 
with  scissors,  as  the  portion  buried  in  the  tissues  is  absorbed,  and  only 
leaves  the  exposed  loop  of  catgut  to  be  picked  off  the  skin  with  thumb 
forceps. 

Secondary  Suture. — If  the  borders  of  the  wound  gape  after  removal 
of  the  stitches,  the  wound  can  be  reunited  by  a  fresh  suture  (secondary 
suture).  This  secondary  suture  is  very  much  used — for  example,  in 
wounds  which  have  been  first  packed,  or  in  wounds  which  have  been 


110  THE   METHOD   OF   UNITING   THE   TISSUES. 

left  entirely  open  during  the  first  few  clays,  or  in  deep,  granulating 
wounds,  etc.  To  avoid  a  repetition  of  the  anaestliesia  when  secondary 
sutures  are  applied,  Nussbaum  has  advised  that  the  secondary  suture  be 
put  in  place  at  the  time  of  the  first  operation.  For  example,  a  mattress 
or  continuous  suture  should  be  inserted  in  advance  in  each  margin  of 
the  wound,  and  then,  later,  the  loops  of  these  sutures  can  be  used  to 
close  the  wound  by  passing  a  silk  thread  through  them. 

Bloodless  Suture. — Besides  the  above-desci'ibed  kinds  of  suture  there  is  a 
bloodless  or  dry  method  of  suture.  The  Arabs  used,  for  closing  a  wound,  an 
insect  {Scarites  pyrcemon)  whose  maxilla  terminated  in  a  small  hook.  The 
borders  of  the  wound  were  approximated  by  these  hooks,  the  body  of  the 
insect  being  removed  and  leaving  only  the  head  with  its  hooks.  Vidal  de 
Cassis  attempted  to  imitate  this  method  of  approximation  with  his  serre-fine. 
This  instrument  is  usually  made  of  a  round  wire  fashioned  so  as  to  have 
jaws  closing  by  a  spring,  which  are  opened  by  pressure  behind  the  point 
where  the  jaws  cross.  It  has  passed  out  of  use,  very  properly,  as  the  method 
is  painful  and  unreliable. 

The  suture  of  tendons,  nerves,  etc.,  is  described  in  the  third  section 
(§  88,  Injuries,  AYounds),  and  suture  of  the  intestine,  bladder,  etc.,  is 
treated  of  in  the  text-book  on  special  surgery. 

§  3  J:.  The  Method  of  uniting  Wound  Surfaces  of  Bone. 
— The  surfaces  of  a  wound  in  a  Ix.me  can  be  held  in  ap- 
position by  periosteal  sutures  only  when  small  bones  are 
concerned.  A  suture  passed  through  the  bone  itself 
is,  of  course,  the  best.  The  necessary  holes  are  made 
in  the  bone  by  drills  (Fig.  93)  worked  by  pushing  the 
wood  or  metal  spool  on  the  instrument  up  and  down, 
and  thus  causing  the  needle  attached  to  the  instrument 
to  rotate.  Silver  wii'e,  Avhicli  is  allowed  to  remain  in 
the  wound,  or  stout  catgut,  are  used  as  suture  materials. 
J.  Henequin  (Rev.  de  Chir.,  August,  1892)  and  V.  Wille 
(Centrbl.  fiir  Chir.,  1892,  p.  46)  have  recommended  a 
very  good  method  of  bone  suture.  Wille's  plan  con- 
sists in  boring  a  hole  through  both  walls  of  a  hollow 
bone  and  dragging  the  silver  wire  through  it  by  means 
of  a  peculiar  "  suture  hook.'' 

Another  excellent  method  of  uniting  the  surfaces 

Fio.  93.— Drill  for  of  a  wound  in  bone  is  aseptic   nailing.     Long,  four- 
bone  sutures.  1        .1  1        1  ■   1  ,-.      ^  ""      /.    n 
cornered  nails  are  used,  which  are  first  very  careiully 

polished  and  then  disinfected  in  a  five-per-cent.  carbolic-acid  solution, 
after  which  they  are  placed  in  absolute  alcohol  and  finally  heated  red- 
hot  in  the  flame  of  a  spirit  lamp.     After  some  three  or  four  weeks 


g34.]     THE   .All-yniOl)   OF   UNITING    WOUND   .SLRl'ACKS   OF    iiONF.      l{\ 

the  loosened  nails  can  be  easily  drawn  out  with  forceps  or  the  fin<;er.s 
and  without  causini>;  the  ])ati<-'nt  ])ain.  Of  course,  care  must  be  taken 
that  the  nails  project  at  least  two  ccntinictres  l)eyond  the  level  of  the 
skin.  Lon<;-  ivory  ])egs  are  sometimes  used  instead  of  metal  nails;  but 
1  have  found  that  ivory  pe<»;s  are  not  so  easily  removed  as  iron  nails, 
as  the  outer  surface  becomes  rou<;h  fi'om  contact  with  the  tissues, 
especially  bone.  The  ivory  i)egs  become  decalcitied  by  the  action  of 
the  carbonic  acid  in  the  tissues,  and  the  remaining  organic  portion  is 
dissolved,  thus  producing  small  pockets  and  cavities  into  which  the 
surrounding  bone  grows.  The  aseptic  nailing  together  of  the  surfaces 
of  a  wound  in  bone,  as  after  resections,  particularly  of  the  knee  and 
ankle,  in  fractures,  separation  of  the  epiphyses,  etc.,  is  entirely  devoid 
of  danger  if  the  operation  is  performed  with  the  strictest  antiseptic 
precautions. 

For  fastening  together  a  divided  bone,  as  in  separation  of  the 
epiphysis  at  the  upper  end  of  the  humerus,  Uelferich  has  recommended 
long,  awl-like  steel  needles,  fitted  with  a  handle  which  unscrews.  These 
are  made  to 'slowly  bore  their  way  into  the  bone.  After  eight  to  four- 
teen days  the  needles  are  removed. 

A  clani])  apparatus  has  been  recommended  for  uniting  the  surfaces 
of  a  bone  wound.  Under  fractures  we  shall  become  acquainted  with 
Malgaigne's  hooks  and  Langenbeck's  screw.  In  cases  of  fracture 
Bircher  has  recently  introduced  the  practice  of  inserting  an  ivory  peg 
into  the  open  ends  of  the  medullary  cavity  of  the  diaphysis,  and  of 
using  ivory  clamps  for  holding 
in  contact  fractures  involving 
the  epiphyses.  In  part  of  the 
cases  the  wound  healed  up  over 
the  ivory  peg ;  in  sixteen  cases 

(out  of  thirty-five)  the  pee  had  Fig.  94.— Union  of  the  ends  of  bones  by  implan- 
^     ,  ,  •,  ,  tation. 

to  be  subsequently  extracted. 

Another  method  of  uniting  a  \vound  in  bone  is  illustrated  in  Fig. 
9-i.  The  somewhat  pointed  extremity  of  one  fragment  (the  femur)  is 
inserted,  for  instance  after  resection  of  the  knee,  into  the  medullary 
cavity  of  the  other  fragment  of  bone  (in  this  case  the  tibia). 

Formation  of  Periosteal  Flaps  and  Transplantation  of  Cartilage  and 
Bone  in  Cases  of  Loss  of  Substance  in  Bone. — Loss  of  sul)stance  in  bone 
can  be  remedied  by  periosteal  flaps  (JSTussbauin)  or  by  the  transplanta- 
tion of  cartilage  or  pieces  of  bone  from  young  animals  (rabbits  and 
dogs).  Gluck  has  attempted  to  supply  loss  of  substance  in  bone  by  the 
implantation  of  dead  bone  and  ivory  (see  §  101,  Treatment  of  Frac- 
tures— Osteoplastic  Method).  The  suture  of  bone  or  the  holding  of  the 


112  •  THE   METHOD   OF   UNITING   THE   TISSUES. 

surfaces  of  a  divided  bone  in  apposition  by  one  of  these  methods  is 
especially  indicated  in  compound  fractures — for  example,  in  compound 
transverse  fracture  of  the  patella  or  olecranon,  in  fractures  of  the  lower 
jaw,  etc.  Besides  these,  it  is  indicated  in  resections  of  joints,  such  as 
the  knee,  in  resections  of  bones  in  their  continuity,  after  temporary 
division  of  bone,  and  in  complicated  harelip  operations,  etc. 


CHAPTEli   IX. 

AMPUTATIONS,    DISARTICl'LATIONS,    AND    RESECTIONS.— GENERAL 
CONSIDERATIONS. 

Performance  of  amputations  and  disarticulations. — Subperiosteal  amputations  and  dis- 
articulations.— History  of  the  methods  of  amputations  and  disarticulations. — After 
treatment. — Bad  sequelae. — Infection  of  the  wound. — Muscular  spasm. — Secondary 
hipmorrhage. — Gangrene  of  the  flaps. — Necrosis  of  the  stump  of  the  bone. — Coni- 
cal stump. — Neuralgia. — Neuromata. — Fatal  results. — Mortality  statistics. — Artifi- 
cial limbs. — The  methods  of  performing  resection. 

§  35.  General  Considerations  in  performing  Amputations  and  Disartic- 
ulations.— By  amputation  (from  amputare,  to  cut  olij  is  understood 
the  operative  removal  of  an  entire  portion  of  an  extremity.  If  a  limb 
is  severed  through  a  joint  the  operation  is  called  a  disarticulation,  in  con- 
tradistinction to  amputation,  in  which  the  portion  of  the  limb  removed 
is  cut  off  by  sawing  through  the  bone  in  its  continuity.  Amputation  is 
not  coniined  to  the  extremities  alone,  but  is  used  to  designate  the  re- 
moval of  certain  portions  of  the  trunk,  like  amputation  of  the  breast, 
the  penis,  or  the  portio  vaginalis.  "\Ye  shall  discuss  here  only  amputa- 
tions and  disarticulations  of  the  extremities. 

The  Indications  for  Amputations  and  Disarticulations  have  markedly 
decreased  in  modern  surgery,  which  leans  more  and  more  towards  con- 
servative methods  of  treatment.  TVith  the  aid  of  the  antiseptic  method 
we  are  now  often  able  to  save  a  limb  which  formerly,  in  the  preanti- 
septic  era,  would  have  fallen  a  prey  to  the  mutilating  effects  of  amputa- 
tion and  disarticulation.  "We  shall  entirely  omit  a  detailed  description 
at  this  point  of  the  indications  for  amputation  and  disarticulation,  as 
there  will  be  opportunity  enough  for  discussing  this  subject  when  we 
take  up  special  diseases  and  injuries.  It  is  sufHeient  to  state  here  that 
these  operations  are  indicated  in  all  diseases  and  injuries  of  the  extrem 
ities  which  threaten  to  destroy  the  whole  limb  or  the  life  of  the  pa- 
tient, and  hence  in  (1)  extensive  injury  to  the  soft  parts  and  bone  which 
precludes  the  possibility  of  saving  the  extremity  in  question,  or  renders 
the  physical  condition  of  the  patient  such  that  he  cannot  withstand  a 
long  confinement  to  bed,  or  in  consequence  of  which  the  extremity,  if 

9  (113) 


114        AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 

spared,  would  be  useless;  or  (2)  in  extensive  inflammation  or  disease  of 
the  extremity  which  would  render  it  completely  incapable  of  perform- 
ing its  functions,  or  which  threatens  the  life  of  the  patient.  Under 
the  latter  heading  come  extensive  gangrene,  malignant  new  growths, 
irreparable  injuries  to  bones  and  joints,  large  ulcers,  spreading  (sep- 
tic) intermuscular  suppuration  with  threatening  systemic  infection,  etc. 
Under  the  separate  injuries  and  diseases  we  shall  refer  again  to  the 
indications  for  amputation  and  disarticulation.  At  present  the  general 
suggestions  just  made  will  be  sufficient. 

When  an  amputation  and  wlien  a  disarticulation  should  be  per- 
formed are  questions  which  in  general  depend  upon  the  nature  of  the 
case  in  hand  and  the  location  of  the  injury  or  disease.  We  shall  dis- 
cuss this  more  fully  in  the  Special  Surgery.  Formerly,  in  the  preanti- 
septic  days,  disarticulation  was  performed  more  frequently,  as  it  dis- 
pensed with  the  dreaded  opening  of  the  medullary  cavity.  In  fact, 
there  were  surgeons  who  went  so  far  as  to  give  up  amputations  for 
this  reason  and  performed  only  disarticulations.  Since  the  introduc- 
tion of  the  aseptic  method  of  operating  this  consideration  is  no  longer 
thought  of.  At  present  the  question  whether  amputation  or  disartic- 
ulation is  better  for  any  particular  case  is  usually  decided  by  practical 
considerations.  Both  forms  of  operation  are  practiced,  and  amputa- 
tion or  disarticulation  is  decided  upon  according  to  the  circumstances 
in  each  individual  case.  In  general,  amputations  are  performed  much 
more  frequently  than  disarticulations,  because  the  former  can  be  car- 
ried out  at  any  part  of  the  extremity,  while  the  latter  are  confined  to 
the  joints. 

The  method  of  dividing  the  soft  parts,  particularly  the  skin,  is 
practically  the  same  in  both  operations.  The  soft  parts  must  be  di- 
vided in  such  a  way  as  to  form  a  good  covering  for  the  bone  stump. 
We  distinguish  three  principal  forms  of  incision — (1)  the  circular, 
(2)  the  flap,  and  (3)  the  racket-shaped  incision. 

§  36.  General  Considerations  in  regard  to  Amputations. — The  field  of 
operation  is  carefully  cleaned  throughout  its  whole  extent  with  soap 
and  a  brush,  shaved,  and  then  disinfected  with  a  three-  to  five-per-cent. 
solution  of  carbolic  acid  or  1  to  1,000  bichloride.  The  patient  is 
placed  in  a  convenient  position,  and  a  particular  duty  is  assigned  to 
each  assistant.  The  operator  stands  so  that  the  limb  to  be  operated 
upon  will  fall  to  his  right.  We  operate  in  all  cases,  if  possible,  with 
the  assistance  of  Esmarch's  artificial  ischaemia,  described  in  §  19.  Dur- 
ing the  operation  all  the  rules  of  antisepsis  must  be  strictly  observed 
by  the  operator  and  his  assistants  ;  no  unclean  finger  or  instrument 
should  come  in  contact  with  the  wound.     The  knife  as  well  as  the  saw 


g;56.]    GENERAL  CONSIDERATIONS  IN  REGARD  TO  AMPUTATIONS.    II5 


should  be  used  carefully  and  gently,  and  pains  should  be  taken  not  to 

bear  down  too  hard   on  the  instruments.     Violent  manipulation  and 

compression  of  tlie  soft  parts  are  to  be  avoided, 

as  well  as  too  vigorous  rubbing  of  the  wound 

with  sponges  or  compresses.     In  fact,  sponging 

can  be  almost  entirely  dispensed  with  when  Es- 

marclfs  artiticial  ischa^mia  is  used. 

I.  Circular  Division  of  the  Soft  Farts  in  a  Single 
Stroke  (Celsus,  Louis). — The  soft  parts,  having 
been  drawn  uj)  by  the  hands  of  an  assistant,  are 
divided  circularly  down  to  the  bone  by  a  single 
stroke  of  the  ami)utation  knife  (Fig.  95)  held  at 
right  angles  to  the  axis  of  the  limb  (Fig.  96). 
The  size  of  the  amputating  knife  should  de- 
pend upon  the  diameter  of  the  limb.  The  am- 
putating knife  is  grasped  in  the  closed  fist,  the 
hand  passed  under  the  limb,  and  the  incision  is 
begun  with  the  part  of  the  edge  nearest  the  han- 
dle, which  is  placed  on  that  portion  of  the  sur- 
face of  the  limb  which  faces  the  operator  (Fig. 
W).  The  blade  is  then  drawn  around  the  entire 
circumference  of  the  limb,  dividing  all  the  soft 
parts  down  to  the  bone.  I  think  it  is  easier 
and  better  to  begin  the  incision  with  the  knife 
in  the  right-angled  position,  point  upwards,  on 
the  side  of  the  limb  which  faces  away  from  the 
operator.  The  knife  is  then  carried  with  a  sawing  motion  around 
about  two  thirds  of  the  circumference  of  the  limb,  dividing  all  the 
soft  parts  down  to  the  bone.  Starting  from  the  beginning  of  this  in- 
cision, the  knife  is 
carried  in  the  reverse 
direction,  dividing 
the  soft  parts  on  the 
side  of  the  limb  fac- 
ing the  operator. 
After  division  of  the 
soft  parts  the  bone  is 
t-awed  through.  Then 
the  cylinder  of  soft 
j)arts  is  drawn  up  on 
the  bone  stump  by  an 
assistant,      while      the  Fig.  96.— Circular  method. 


Fig.  95. — Amputation 
knives. 


U6         AMPUTATIONS,   DISARTICULATIONS,   AND   RESECTIONS. 


operator  grasps  the  extremity  of  the  l^one  stump  with  Luer's  or  Lang- 
enbeck's  boue  forceps  (Figs.  67,  d,  and  68),  and  elevates  or  pushes  back 
the  periosteum  by  means  of  a  periosteal  elevator  (raspatory, 
Fig.  63)  a  distance  equal  to  about  half  the  diameter  of  the  limb. 
At  this  point  the  bone  is  again  sawed  through,  thus  allowing  the 
cylinder  of  soft  parts  to  completely  cover  the  stump  of  bone 
and  the  edges  of  the  skin  to  be  united,  usually  in  a  transverse 
line,  without  tension  on  the  sutures.  In  amputations  of  ex- 
tremities containing  two  bones,  such  as  the  leg,  the  forearm, 
the  metacarpus  and  metatarsus,  the  muscles  and  soft  parts 
Iving  between  the  bones  must  be  divided  before  sawing  the 
bones.  For  this  purpose  a  small,  pointed,  double-edged  knife, 
sometimes  called  a  catline,  is  best  (Fig.  97).  This  knife  is  in- 
serted in  the  space  between  the  bones  and  the  soft  parts  di- 
vided by  cutting  first  with  one  edge  against  one  of  the  bones 
and  then  with  the  other  edge  against  the  other  bone.  This 
procedure  is  then  repeated  by  inserting  the  knife  from  the 
opposite  side  into  the  space  between  the  bones.  Instead  of 
the  two-edged  knife,  a  small  scalpel  can  be  used  for  this  pur- 
After  dividing  the  soft  parts  in  the  space  between  the  bones 
and  laying  the  bones  free,  the  latter  are  sawed  in  such  a  way  that  the 
division  of  both  is  completed  at  the  same  time.  Thus,  in  amputations 
of  the  leg  the  tibia  is  first  sawed  about  three  quarters  through  before 
one  begins  to  saw  the  fibula,  and  then  both  are  completely  sawed  through 
at  the  same  time. 


Fio.  97. 
Catline. 


pose. 


Fig.  98. — Division  of  a  bone  bv  the  saw. 


FiG.  99. — Split  compresses. 


For  sawing  the  bones  in  amputations  it  is  best  to  u,«e  the  bow-saw 
(see  page  83,  Fig.  70.  h.  c)  in  the  way  illustrated  in  Fig.  98 — i.  e., 
the  saw  is  placed  close  to  the  soft  parts,  at  right  angles  to  the  thumb 
of  the  left  hand,  which  is  placed  upon  them.     To  prevent  injury  to 


§36.]    GENERAL  CONSIDERATIONS  IN  RF:GARD  TO  AMPUTATIONS.    II7 

the  soft  parts  they  are  retracted  by  a  split  ase})tic  compress  (Fig.  OOj  or 
the  hand  of  an  assistant.  The  distal  portion  of  the  limb  is  held  by  an 
assistant,  and  allowed  to  drop  a  little  as  the  sawing  progresses,  so  that 
the  saw  does  not  become  jammed.  If  projecting  spicules  of  bone  re- 
main after  the  sawing  is  completed  they  must  be  cut  or  smoothed  off 
by  bone  shears  or  forceps,  or  the  metacarpal  saw  or  chisel  may  be  used 
for  this  purpose,  as  for  removing  the  anterior  projecting  border  of  the 
tibia. 

After  amputation  by  the  ordinary  circular  division  of  the  soft 
parts  three  drainage  tubes  are  generally  inserted — one  at  each  angle  of 
tlie  wound,  and  one  in  the  centre  of  the  posterior  skin  flap;  but  in 
small  stumps  the  latter  drain  alone  is  sufficient.  A  continuous  catgut 
suture  with  several  interrupted  silk  tension  sutures  should  be  used  to 
close  the  wound. 

Modifications  of  the  Circular  Division  of  Soft  Parts  in  One  Sweep. — 
After  cutting  the  soft  parts  circularly  in  one  sweep  down  to  the  bone, 
as  just  described,  the  cylinder  of  soft  parts  is  drawn  up  or  retracted  by 
an  assista;nt.  The  muscular  fibres  still  adhering  to  the  bone  cause  the 
surface  of  the  wound  to  have  the  shape  of  a  cone.  A  knife  is  then 
carried  circularly  through  the  base  of  this  cone  down  to  the  bone  at 
the  point  where  the  latter  is  to  be  divided.  If  the  covering  for  the 
bone  stump  thus  made  out  of  the  soft  parts  is  not  sufficient,  the  mus- 
cles are  then  freed  from  the  bone  by  a  scalpel.  The  bone  can  then  be 
sawn  through  with  or  without  first  elevating  the  periosteum.  By  this 
method  the  surface  of  the  relaxed  wound  is  made  to  assume  the  shape 
of  a  short,  hollow  cone  with  its  apex  towards  the  trunk. 

The  division  of  the  soft  parts  in  the  form  of  a  cone  can  be  omitted, 
and  the  nmscles  simply  freed  from  around  the  bone  by  means  of  a 
small  scalpel  and  retracted  by  tlie  fingers  of  the  left  hand. 

The  Elevation  of  the  Periosteum. — It  is  not  always  necessary  to  ele- 
vate the  periosteum  from  the  bone  before  sawing  it  through,  I  usu- 
ally omit  it.  According  to  my  experience,  the  bone-forming  power  of 
the  elevated  periosteum  does  not  affect  the  subsequent  condition  of  the 
stjump. 

On  account  of  the  rapidity  with  which  it  could  be  done,  the  circu- 
lar method,  performed  with  one  sweep,  used  to  be  much  employed 
when  operations  were  carried  ont  without  anaesthesia,  but  at  the  pres- 
ent time  it  is  less  often  used.  In  fact,  it  is  little  suited  for  extremities 
having  powerful  muscles,  for  it  provides  a  more  or  less  insufficient 
covering  of  soft  parts  and  of  skin  for  the  bone  stump,  and  therefore 
is  conducive  to  the  formation  of  the  so-called  conical  stump.  But.  on 
the  other  hand,  this  method  is  a  perfectly  proper  one  for  performing 


118         AMPUTATIONS,   DISARTICULATIONS,   AND   RESECTIONS. 


Fio.  100. — Formation  of  a  cutaneous  euflf  in  a  circular  amputation  at 
two  levels. 


amputations  on  children  and  thin  subjects,  particularly  in  the  case  of 
limbs  containing  only  one  bone. 

11.  Circular  Method  of  dividing   the   Soft   Parts   at   Two   Different 
Levels. — An  incision  is  carried  circularly  around  the  limb  through  the 

skin  down  to  the 
fascia.  The  skin  is 
then  drawn  up  by 
an  assistant,  while 
it  is  freed  from  the 
subjacent  parts  by 
carrying  a  knife, 
held  at  right  an- 
gles to  the  axis  of 
the  limb,  circularly 
around  the  latter  at 
the  edge  of  the 
skin,  cutting  down 
to  the  fascia  (Fig. 
100),  or  by  dissecting  the  skin  and  subcutaneous  tissue  from  the  deeper 
tissues  by  means  of  a  scalpel.  AVhen  the  skin  has  been  thus  sufficient- 
ly freed  from  the  fascia  it  is  turned  back  in  the  form  of  a  cuff,  the 
length  of  which  should  equal  about  half  the  diameter  of  the  limb.  A 
circular  incision  through  all  the  soft  parts  down  to  the  bone  is  then 
made  close  to  the  attached  edge  of  the  cutaneous  cuff,  and  the  bone  is 
then  sawed  in  the  manner  already  described.  Here  also  it  is  a  good 
plan  to  separate  the  muscular  insertions  from  the  bone  foi"  a  short  dis- 
tance to  insure  a  sufficient  covering  for  the  stump. 

Funnel-shaped  Method. — The  so-called  funnel-shaped  method  of 
dividing  the  soft  parts  (Alanson)  is  only  a  modification  of  the  method 
just  described.  The  skin  is  first  divided  circularly,  and  the  knife  is 
then  applied  at  the  margin  of  the  retracted  skin,  having  its  edge 
directed  obliquely  upwards  and  at  the  same  time  towards  the  bone,  in 
which  direction  it  is  carried  through  the  muscles  down  to  the  bone. 
In  this  way  a  conical-shaped  wound  surface  is  made,  with  its  apex 
towards  the  upper  end  of  the  bone. 

III.  The  Flap  Methods. — The  flap  methods  vary  in  the  thickness, 
shape,  and  length  of  the  flaps. 

At  the  present  time  flaps  are  generally  made  to  consist  only  of  skin, 
or  skin  and  subcutaneous  tissue,  as  it  is  well  known  that  the  muscles  in 
the  flap  covering  the  bone  stump  subsequently  disappear  entirely  by 
fatty  degeneration.  But  it  is  an  excellent  plan  to  fashion  flaps  of  both 
cutaneous  and  muscular  tissue  whenever  the  skin  is  very  thin  and  badly 


§36.]    GP:XP]IIAL  CONSIDERATION'S  IN  REGARD  TO  AMPUTATIONS,    ny 


Fig.  101. — Formation  of  two  semilunar  skin  flaps. 


nourislied.    Tlie  shape  and  j)osition  of  the  flaps  vary  very  much,  tliongh 

anterior  and  posterior  flaj)s  are  usually  made  either  of  equal  length,  or 

a     long    anterior    and 

short  })osteri()r  flap  are 

made,  in  order  that  the 

suture  line  shall  come 

to  lie  more  posteriorly. 

The  incision  for  the 
cutaneous  flaps  may  be 
made  in  the  same  way  as  in  the  circular  method  of  amputating  in  two 
stages  just  described,  and  then  longitudinal  incisions  some  five  or  six 
centimetres  long  are 
made  on  the  inner  and 
outer  aspect  of  the  ex- 
tremity, thus  forming 
two  cutaneous  flaps  of 
equal  length,  an  ante- 
rior and  a  posterior. 
These  are  then  freed 
from  the  fascia  and 
turned  back.  The  mus- 
cles are  divided  at  the 
point  where  the  cuta- 
neous flaps  are  turned  back,  just  as  in  the  circular  method  of  amputa- 
ting in  two  stages.  Another  way  is  to  form  two  semilunar-shaped  skin 
flaps,  either  in  front 
and  behind  or  laterally, 
using  a  large  scalpel 
with  a  blade  convex  on 
the  edge.  The  flaps 
of  skin  are  dissected 
from  the  fascia  and 
turned  back  (Fig.  101). 

It  is  a  very  good 
plan  to  make  a  long, 
semilunar-shaped  ante- 
rior flap  of  skin  with 
a  small  posterior  flap 
(Fig.  102).  The  form- 
er must  be  long  enough  F'«-  I03.-Anterior  o-efj;;'?;^^^^fj-  ^^  P'^^^^"'^^  '''^^^- 
to  cover  the  entire  cut 
surface  like  a  curtain.     The  overhanging  anterior  flap  is  made  in  the 


Fig.  102. — Formation  of  a  larcre  anterior  and  small  posterior 
skin  flap. 


120         AMPUTATIONS,   DISARTICULATIONS,   AND   RESECTIONS. 


Fig.  104.— Formation  of  a  flap  of  skin  and  muscle  by  an  in- 
cision from  without  inwards. 


simplest  way,  by  cutting  an  anterior  semilunar-shaped  cutaneous  flap 
and  freeing  it  from  the  subjacent  parts.  The  base  of  the  flap  should 
be  equal  to  about  half  the  circumference  of  the  limb,  and  its  lengtli 
should  equal  its  sagittal  diameter.     A  similar  but  smaller  cutaneous  flap 

is  then  cut  from  the 
posterior  half  of  the 
circumference  of  the 
limb  and  dissected  from 
the  fa.scia. 

A  very  simple   way 

of     carrying     out     this 

method    of    amputation 

by  a  long  anterior  flap, 

after  the  latter  has  been 

cut  and  turned  back,  is 

to    divide    the    skin    on 

the  posterior  portion  of 

the  circumference  of  the  limb  by  a  single  circular  sweep  of  the  knife. 

The  posterior  flap  is  then  dissected  back  from  below  upwards,  as  usual, 

Vjy  strokes  of  the  knife  held  at  right  angles  to  the  axis  of  the  limb, 

and  the  muscles  are  then  cut  circularly  by  a  single 

sweep  of  the  knife  (Fig.  103). 

Some  surgeons  prefer  to  include  the  fascia  in 
the  skin  flaps,  freeing  skin  and  fascia  together  from 
the  underlying  muscles,  as  they  believe  that  the 
skin  flaps  are  better  nourished  in  this  way  by  the 
extensive  network  of  vessels  lying  between  the 
skin  and  fascia,  particularly  if  the  portion  of  skin 
in  question  is  loosely  attached  and  thin.  I  do  not 
like  these  flaps  of  combined  skin  and  fascia,  and 
agree  with  Oberst  that  the  fascia,  on  account  of 
its  poor  blood  supply,  especially  if  the  conditions 
for  circulation  are  unfavorable,  is  liable  to  necrose 
and  so  interfere  with  primary  union.     I  think  it 


Fia.  105. — Disarticulation 
of  the  middle  finger: 
1,  extensor  tendon  ;  2, 

iie.xor  tendon  and  near  better  to  form  cutaucous  flaps  witliout  the  fascia. 

bv  the  two  licrated  ditf-    t^    .-,  i  •       •  .         -^   i  i      j-  i  •  n 

It  the  skin  is  not  suitable  for  making  flaps  on  ac- 
count of  being  too  thin,  I  prefer  the  circular 
method  of  amputation,  carrying  the  knife  to  the 
bone  in  one  sweep,  or  the  method  in  which  the 

flaps  include  both  skin  and  muscular  tissue. 

The  formation  of  flaps  consisting  of  both  skin  and  muscular  tissue 

is  not  at  present  so  much  in  vogue  as  formerly.     The  wound  surface 


ital  arteries  and  the 
nerves.  In  the  center 
of  the  wound  is  seen 
the  articular  surface  of 
the  metacarpus. 


gyo.J    CiKNKKAL  CONSIDP]RATIUNS  IN   KK(iAI{I)  Tu  AMl'L'TATIONS.    121 


ii}  too  large,  the  flaps  are  too  lieavy,  and  the  vessels  are  usually  cut 
ol)li(|uely.  These  flaps  are  formed  either  by  cutting  from  without  in- 
wards (Fig.  104),  or  in  the  reverse  direction,  fi'oni  within  outwards, 
hy  means  of  transflxion.  In  the  latter  method  a  double-edged  knife  is 
inserted  close  to  the  bone,  at  the  base  of  the  flap  to  be  formed  ;  then 
the  knife  is  carried  with  a  sawing  motion  obliquely  downwards  and  out- 
wards. iVll  transflxion  methods  are  bad,  because  the  vessels  are  often 
wounded  or  divided  in  two  dill'erent  places.  It  was  foi'merly  used  very 
often,  when  operations  had  to  be  performed  rapidly  without  anaesthesia. 

IV.  The  Oval  or  Racket  Incision  (Fig.  105). — This  is  a  compromise 
between  the  single  circular  sweep  of  the  knife  and  the  flap  method. 
It  is  chiefly  used  for  disarticulating  fingers  and  toes,  but  it  is  seldom 
made  use  of  in  amputating.  It  is  really  an  obliquely  placed  circular 
amputation — i.  e..  two  lateral  incisions  are  made,  which  meet  at  a  sharp 
upward  angle  on  the  back  of  the  liml),  and  in  a  slight  downward  curve 
on  the  front. 

The  Treatment  of  Amputation  Wounds. — Haemorrhage  after  ampu- 
tation is  arrested  by  seizing  separately  all  the  divided  vessels,  both 
arteries  and  veins,  in  the  bloodless 
stump  with  self-locking  haemostatic 
clamps  and  then  ligating  them  with 
catgut  or  aseptic  silk  (Fig.  106).  To 
find  the  small  muscular  branches  in 
the  surface  of  the  bloodless  stump, 
one  should  follow  the  muscular  in- 
terspaces, where  the  vessels  can  be 
discovered  and  grasped  with  clamps. 
If  any  vessel  cannot  be  drawn  out 
or  isolated,  it  should  be  secured  by 
passing  a  sharply-curved  needle  car- 
rying a  catgut  suture  through  the 
soft  parts  around  the  bleeding  vessel 

(]")age    90,    Fig.    T8).      The    suture    is    Fm.  106.— Ligation  of  the  vessels  in  an  am- 

tben  tied  so  as  to  include  the  soft 

parts  and  the  vessel.  Small  vessels  can  be  closed  l)y  torsion,  as  de- 
scribed in  §  28.  After  all  the  vessels  in  sight  have  been  ligated,  the 
Esmarch  elastic  tourniquet  is  removed,  while  the  amputation  wound 
is  elevated  and  pressure  exerted  upon  it  l)y  aseptic  sponges.  Pressure 
lasting  a  couple  of  minutes  is  the  best  means  of  arresting  the  ensuing 
parenchymatous  hnemorrhage,  which  is  very  apt  to  be  considerable  im- 
mediately after  the  removal  of  the  Esmarch  tourniquet,  on  account  of 
the  vasomotor  paralysis  that  it  causes. 


122         AMPUTATIONS,  DISARTICULATIONS,   AND  RESECTIONS. 

When  the  liaemorrhage  has  been  very  carefully  arrested  the  large 
nerve  trunks  are  drawn  out  of  the  wound  and  cut  off  with  scissors,  to 
prevent  the  possibility  of  any  subsequent  neuralgia  or  the  formation  of 
amputation  neuromata.  After  this  the  wound  is  disinfected,  together 
with  the  parts  surrounding  it,  by  irrigation  with  a  l-to-1,000-5,000 
bichloride  solution,  or  a  three-per-cent.  solution  of  carbolic  acid,  and 
its  margins  are  united  by  sutures  and  drainage  tubes  inserted.  If  the 
asepsis  has  been  perfect  throughout,  there  is  no  necessity  of  antiseptic 
irrigation  of  the  wound,  as  this  only  causes  irritation  and  increases  the 
subsequent  discharge  from  the  wound.  It  is  sufficient  to  wash  out  the 
wound  with  a  sterilised  seven-tenths-per-cent.  solution  of  common  salt 
or  simple  warm  boiled  water.  The  drainage  tubes  are  fastened  to  the 
skin  by  a  suture,  one  tube  being  generally  placed  in  the  posterior  flap, 
and,  when  necessary,  others  are  placed  in  the  angles  of  the  wound  at 
each  side  (§  31).  The  wound  is  closed  (§  33)  by  inserting  several  in- 
terrupted tension  sutures  and  then  a  continuous  catgut  suture.  Great 
pains  must  be  taken  in  inserting  the  sutures.  They  should  be  even, 
and  hold  the  margins  of  the  wound  in  perfect  apposition.  All  drawing 
and  tension  must  be  avoided.  Neuber  recommends  the  use  of  several 
rows  of  sutures  for  closing  an  amputation  wound.  He  sutures  first  the 
periosteum,  then  the  muscles,  and  finally  the  skin,  and  thus  avoids  the 
formation  of  any  pockets.  According  to  my  ideas,  this  form  of  sutur- 
ing is  unnecessary  and  even  bad,  and  I  have  found  that  an  aseptic 
dressing,  applied  so  as  to  exert  suitable  pressure,  is  entirely  suflicient  to 
prevent  the  formation  of  pockets. 

An  aseptic  protective  covering  which  exerts  moderate  pressure  is 
the  most  suitable  form  of  dressing  for  amputations.  I  usually  moisten 
the  wound  with  a  1  to  1,000  solution  of  bichloride  of  mercury,  and 
then  cover  it  with  several  layers  of  well-dried  bichloride  or  iodoform 
gauze,  or  with  gauze  sterilised  by  dry  heat  at  a  temperature  of  100°  C. 
Over  this  I  place  sterilised  cotton  or  my  own  wool  dressing.  Moss  or 
jute  cushions  or  pads  are  also  good  (see  Dressing  Materials,  §  45).  The 
dressings  are  held  in  position  by  mull  or  gauze  bandages ;  the  stump 
is  placed  in  a  slightly  elevated  position,  and  left  for  the  time  being  un- 
covered, so  that  any  secondary  haemorrhage  may  be  recognised  at  once. 

Subperiosteal  Amputations.— Oilier,  particularly,  has  uphold  subperiosteal 
amputations,  I'easoning  from  the  results  obtained  from  experiments  made  on 
animals.  He  makes  a  flap  from  the  periosteum  to  promote  primary  union 
of  the  deeply  lying  parts,  and  to  prevent  inflammatory  complications  from 
occurring  in  the  medullary  cavity.  But  when  this  method  is  used  on  man 
the  results  are  not  so  good  as  the  experiments  on  animals  would  seem  to 
indicate.     At  present  Oilier  has  himself  given  up  periosteal  flaps,  and  even 


§37.]         THE   METHOD   UF    PERFORMING    DISARTICULATIONS.  123 

considers  them  liarniful  in  children,  on  account  of  the  tendency  to  form 
osteophytes,  and  superlluous  in  a(kilts  since  tlie  inti'odiiction  of  Lister's 
method  of  antiseptic  treatment  of  wounds.  On  the  other  hand,  (JlHer  is  a 
very  warm  advocate  of  suhi)eriosteal  disarticulation  (see  Disarticulations). 

Amputation,  with  Scraping  Out  of  the  Diseased  Medullary  Cavity.— In 
diseases  of  the  marrow  of  bone,  such  as  suppurative  osteomyelitis,  Konig 
and  Stoll  have  performed  amputation  accompanied  by  scraping  out  the 
marrow,  and  have  obtained  good  results.  In  this  way  disarticulation  at  the 
adjoining  joint  above  can  be  avoided. 

§  37.  The  Method  of  performing  Disarticulations. — The  technique 
is  in  the  main  the  same  as  for  amputations.  The  metliod  by  circular 
incisions  at  two  levels,  with  turning  back  of  a  cutaneous  cuff,  can  be 
used,  or  flaps  may  be  cut  of  skin,  or  skin  and  muscular  tissue  combined. 

In  disarticulations,  a  long  anterior  overhanging  flap  and  a  small 
posterior  one  are  much  used,  and  are  made  as  described  above  (Figs. 
102,  104).  In  disarticulations  at  the  ankle  or  medio-tarsal  joint,  or 
of  the  fingers  or  toes,  the  posterior  flap  can  be  made  the  larger.  For 
disarticulation  at  the  small  joints  of  the  fingers  or  toes,  especially  the 
metatarso-  and  metacarpo-phalangeal  joints,  the  racket  incision  is  very 
often  used  (Fig.  105). 

After  dividing  the  overlying  soft  parts  in  the  form  of  skin  flaps, 
or  flaps  of  skin  and  muscular  tissue  combined,  or  after  making  the 
circular  incision  in  two  stages  and  turning  back  the  cutaneous  cuff,  the 
ligaments  of  the  joint  are  made  tense  and  the  joint  opened.  When- 
ever it  is  necessary,  any  prominent  part  entering  into  the  formation  of 
the  joint  can  be  cut  away  ;  and  it  is  sometimes  best  to  extirpate  the 
synovial  membrane  completely,  in  order  to  obtain  a  wound  surface  to 
which  the  cutaneous  flaps  may  unite  more  rapidly.  The  details  for 
performing  disarticulations  are,  in  general,  precisely  similar  to  those 
for  amputations. 

For  the  method  of  performing  disarticulation  on  particular  joints, 
as  well  as  the  various  amputations,  the.  reader  is  referred  to  the  text- 
book on  special  surgery. 

Subperiosteal  Disarticulation.— Oilier,  especially,  hes  recommended  the 
regular  use  of  subperiosteal  disarticulation.  Ollier's  description  is  as  fol- 
lows :  The  same  incision  is  made  as  for  resection  of  the  particular  joint  in 
question  (see  §  40),  dividing  at  the  same  time  both  capsule  and  periosteum. 
By  means  of  a  raspatory  the  periosteum  is  elevated  from  the  bone  and 
pushed  aside  from  the  joint,  together  with  such  muscular  insertions  as  are 
present;  the  head  of  the  bone  is  then  eHUcleated,  and  the  soft  parts  cut  trans- 
versely to  the  axis  of  the  limb.  Extensive  new  formation  of  bone  has  been 
observed  after  subperiosteal  disarticulation,  not  only  in  animals,  but  also  in 
man  in  early  life.     This  is   especially  true  of  subperiosteal  disarticulation 


]2i         AMPUTATIONS.   DISARTICULATIONS.   AND   RESECTIONS. 

and  amputation  throusrh  the  upper  end  of  the  metatarsus  or  metacarpus,  and 
also  after  disarticulation  at  the  tihio-tareal  joint  with  preservation  of  the 
periosteum  of  the  os  calcis.  Oilier  says  that  James  Shuter  of  London  has 
seen  a  new  bone  develop  which  was  movable  in  the  hip  joiiit  after  subperios- 
teal disarticulation  at  thLs  joint.  The  subperiosteal  and  subcapsular  shelling 
out  of  the  bone  is  probably  of  most  use  in  case  of  disarticulations  for  gun- 
shot injuries. 

History. — During  the  middle  ages  and  until  the  close  of  the  sixteenth 
century  amputations  were  done  in  the  most  horrible  ways,  on  account  of  the 
inefficient  methods  then  in  vogue  for  arresting  haemorrhage,  and  usually 
ended  fatally.  The  bleeding  was  checked  by  encircling  the  member  to  he 
operated  upon  with  a  sti'ong  rope,  or  the  red-hot  ii'on  was  used;  boiling  oil 
was  poured  over  the  wound,  or  the  operation  was  performed  with  red-hot 
knives.  Permanent  constriction  of  the  limb  and  caustics  were  also  some- 
times used.  The  technique  was  very  gi-eatly  advanced  by  the  introduction 
of  the  ligature  of  vessels  by  Ambrose  Pare  and  his  followei"S  (1659-1692),  and 
after  this  by  the  invention  of  the  tourniquet  by  Morel  (1674).  The  ligatui-e 
of  vessels  for  arresting  haemorrhage  had  been  well  understood  by  the  sur- 
geons of  antiquity,  and  was  in  general  iLse  in  the  time  of  the  Roman  Empire. 
The  ligature  was  afterwards  entirely  forgotten,  as  has  been  mentioned,  and 
was  later  rediscovered  by  Pare. 

In  more  recent  times  amputation  was  occasionally  performed  by  the 
ecraseur  (Chassaignac),  the  galvano-cautery  (Brunsj.  and  the  elastic  ligature 
(Dittel).  But  now  all  these  methods  have  become  simply  matters  of  history 
since  the  introduction  of  antiseptics. 

§  38.  The  After-treatment  of  Amputations  and  Disarticulations. — The 
after-treatment  of  amputations  and  di.-?articulations  is  very  simple  if  no 
fever  occurs  and  the  wound  runs  a  normal  course  in  healing.  The 
first  dressing  should  not  be  disturbed  till  the  time  arrives  for  removing 
the  drains — i.  e.,  till  the  second,  third,  or  fourtli  day,  according  to  tlie 
size  of  the  wound.  Some  of  the  stitches  are  also  taken  out  at  tlie  same 
time.  Then  the  second  dressing  is  applied,  and  it  is  often  the  last.  If 
fever  occurs,  or  if  the  patient  complains  of  pain,  the  dressing  should 
be  changed  earlier. 

For  the  details  of  treating  the  patient  who  has  been  operated  upon, 
reference  is  made  to  ^  22. 

Bad  Results. — Since  the  introduction  of  the  present  antiseptic  meth- 
od of  operating  and  treating  wounds  the  immediate  bad  results  which 
have  been  observed  to  follow  amputations  atid  disarticulations  are  in- 
frequent. It  is  generally  expected  that  healing  will  take  place  without 
any  reaction.  The  occurrence  of  wound  infection — such  as  suppura- 
tion, pysemia,  septicaemia,  erysipelas,  and  osteomyelitis,  so  frequently  ob- 
served in  the  preantiseptic  period — is  now  exceptional,  and  only  takes 
place  when  an  extremity  is  operated  upon  which  is  already  infected, 
or  when  the  rules  of  asepsis  are  not  rigidly  adhered  to.     For  the  treat- 


§38.]  AFTER-TREATMENT   OP"   AMPUTATIONS.  125 

ment  of  tlit^se  diseases  of  wounds  resulting  from  infection,  as  well  as 
for  the  treatment  of  shock,  delirium  tremens,  etc.,  reference  is  made 
to  §  02  to  §  75. 

Amongst  the  other  immediate  bad  results  after  amputation  we  mav 
mention  the  occurrence  of  cramps  or -violent  contractions  of  the  mus- 
cles in  the  stump.  These  are  liable  to  come  on  soon  after  the  opera- 
tion, and  are  best  treated  by  subcutaneous  injections  of  morphine  and 
by  fixation  of  the  stump  by  means  of  light  sand-bags,  etc.  (See  also 
§  64,  Delirium  Tremens.) 

Secondary  hgemorrhage  also  occurs  much  less  frequently  than  it 
formerly  did,  because  we  have  learned  to  take  great  pains  to  arrest  all 
bleeding  during  the  operation.  Secondary  haemorrhage  starts  either 
from  an  unsecured  vessel  which  had  retracted  at  the  time  that  the 
bleeding  from  the  stump  was  being  stopped,  or  from  a  vessel  which 
had  been  tied  off  but  had  opened  again.  In  such  cases  of  secondary 
Ijaemorrhage  from  an  artery  often  nothing  Imt  the  reopening  of  the 
wound  and  the  securing  of  the  bleeding  vessel  will  suffice  to  check  it. 
The  best  way  of  treating  parenchymatous  secondary  hfemorrhage  or 
oozing  is  to  apply  an  aseptic  dressing  in  such  a  manner  as  to  exert 
proper  pressure  and  to  place  the  stump  in  an  elevated  position.  At  a 
later  stage  in  the  process  of  healing  it  is  still  possible  for  secondary 
haemorrhage  to  occur  from  a  perforation  in  the  wall  of  the  vessel  re- 
sulting from  suppuration  when  the  wound  does  not  heal  by  primary 
union.  The  treatment  of  this  is  also  practically  the  same — i.  e.,  the 
haemorrhage  sliould  be  stopped  by  applying  a  ligature  to  the  point 
from  which  blood  issues. 

If  the  skin  is  very  thin,  or  if  the  skin  flaps  lie  upon  a  non-vascular 
surface  like  cartilage,  as  is  the  case  in  disarticulations,  or  if  the  dress- 
ings are  applied  so  as  to  exert  too  much  pressure,  there  is  a])t  to  be  a 
more  or  less  extensive  death  or  gangrene  of  the  flaps.  In  such  cases 
one  must  either  await  the  separation  of  the  damaged  portion  of  the 
flap,  or,  if  the  gangrene  is  too  extensive,  a  higher  amputation  must  be 
performed. 

Sometimes  necrosis  occurs  in  the  stump  of  the  bone,  especially  if 
there  has  been  suppuration.  Under  these  circumstances  one  must  wait 
until  the  sequestrum  has  become  loosened,  and  then  remove  it.  The 
bone  stump  does  not  necrose  if  the  wound  heals  normally  and  without 
reaction. 

Another  bad  result  after  amputation  is  the  so-called  conical  stump. 
This  may  be  the  fault  of  the  method  of  operating — i.  e.,  the  cutaneous 
flaps  were  made  too  short  for  sufficiently  covering  the  bone  stump,  or 
it  may  be  due  to  the  death  of  part  of  the  cutaneous  flaps,  or  to  retrac- 


120         AMPUTATIONS,   DISARTICULATIONS,   AND  RESECTIONS. 

tion  of  the  soft  parts  as  a  result  of  STippnration.  This  latter  cause  was 
relatively  common  in  the  preantiseptic  period  of  surgery.  At  present 
conical  amputation  stumps  are  rare,  and  are  usually  the  result  of  an  un- 
skilful performance  of  the  operation.  In  a  well-marked  conical  stump 
the  end  of  the  bone  projects  from  the  soft  parts  through  the  granulat- 
ino-  surface  of  the  w^ound,  and  either  cicatrisation  does  not  take  place, 
or  the  slowly  forming,  adherent  scar  is  so  tense  and  sensitive  that  the 
use  of  the  stump  and  the  wearing  of  an  artificial  limb  are  impossible. 
Under  such  conditions  there  is  nothing  to  be  done  but  to  perform  a 
reamputation  or  a  subperiosteal  resection  of  the  bone.  The  latter  is 
best  carried  out  by  making  a  longitudinal  incision  through  the  soft 
parts  and  periosteum  down  to  the  stump  of  bone,  care  being  taken  to 
avoid  large  vessels  and  nerves  ;  the  periosteum  with  the  overlying  soft 
parts  are  then  separated  by  means  of  the  raspatory  and  periosteal 
elevator  from  the  bone,  and  a  sufficiently  long  piece  of  bone  is  removed 
with  the  saw  or  hammer  and  chisel. 

Since  the  era  of  aseptic  surgery,  the  neuralgia  of  the  amputation 
stump  which  used  to  occur  after  suppuration  is  seldom  observed.  The 
pain  was  usually  caused  by  the  stumps  of  the  nerves  becoming  included 
in  the  contracting  cicatrix  which  followed  extensive  suppuration.  In 
other  cases  the  pain  is  caused  by  a  hyperplastic  process  occurring  in  the 
ends  of  the  nerves  and  forming  the  so-called  neuromata. 

The  amputation  neuroma  is  usually  a  club-shaped  thickening  of  the 
extremity  of  the  nerve,  and  consists  of  connective  tissue  with  more  or 
less  numerous  bundles  of  newly  formed  nerve  fibres.  Yery  severe 
neuralgic  paroxysms  are  occasioned  by  these  neuromata  and  are  aroused 
by  the  slightest  pressure.  The  neuralgia  which  results  from  cicatricial 
contraction,  and  from  neuromata,  is  best  prevented  by  keeping  the  am- 
putation wound  aseptic,  and  by  drawing  out  the  ends  of  the  large  nerves 
with  forceps  after  every  amputation,  and  cutting  off  a  considerable  por- 
tion with  scissors  in  order  that  the  nerves  may  retract  well  between  the 
muscles.  Moreover,  great  care  should  be  taken  not  to  include  nerves 
in  the  ligatures  placed  on  the  vessels.  The  treatment  of  neuralgia  oc- 
curring in  a  stump  consists  in  the  excision  of  a  long  piece  of  the  affected 
nerve  trunk  (neurectomy),  and  in  the  extirpation  of  any  neuj'omata 
which  may  be  present. 

During  the  first  few  days  or  weeks  many  patients  who  have  under- 
gone an  amputation  complain  of  radiating  pains  of  greater  or  less  se- 
verity, which,  however,  gradually  disappear  in  the  great  majority  of 
cases.  On  account  of  irritation  of  the  ends  of  the  sensory  nerve  fibres 
which  originally  supplied  the  fingers  or  toes,  these  patients  feel  pain  re- 
ferred to  those  parts  though  they  no  longer  possess  them.     The  sensa- 


§39.]  ARTIFICIAL   LIMBS.  127 

tions  referred  to  the  portions  of  the  extremities  whicli  no  hjn<:;er  exist 
last  a  variable  length  of  time— often  a  year — and  patients  are  very 
likely  to  dream  that  they  still  have  their  lost  limh. 

Death  following  Amputation  and  Disarticulation. — A  fatal  result  fol- 
lowint;  amputation  or  disarticulation  is  either  caused  by  one  of  the 
forms  of  wound  infection,  such  as  septicaemia,  pyaemia,  erysipelas,  or 
tetanus,  or  by  collapse,  by  ana?mia  from  great  loss  of  blood,  by  second- 
ary haemorrhage,  delirium  tremens,  fat  emboli,  or  other  intercurrent 
diseases.  In  general,  age  does  not  play  so  important  a  part  in  the  prog- 
nosis of  amputations  and  disarticulations  as  it  formerly  did,  because  we 
have  learned  how  to  avoid  loss  of  blood,  and  healing  is  more  rapid  with 
the  aseptic  method  of  operating.  It  often  happens  in  old  people  that 
there  is  marked  atheromatous  degeneration  of  the  arteries,  and  yet  the 
wound  will  heal  satisfactorily.  Furthermore,  syphilis,  tuberculosis,  and 
kidney  disease  have  no  such  deleterious  elfect  on  healing  as  was  for- 
merly believed.  In  every  case  the  prognosis  after  an  amjiutation  is 
favourable  if  there  are  no  complications,  and  if  there  has  been  no  trans- 
gression of  the  rules  of  antisepsis. 

Mortality  of  Amputations. — The  mortality  of  aseptic  amputations  varies 
with  the  nature  of  the  case  and  the  presence  or  absence  of  complications. 
According  to  Oberst,  of  2C0  uncomplicated  amputations  14  died,  a  mortality 
of  5 '4  per  cent. ;  but,  on  the  other  hand,  there  were  39  deaths  in  91  cases 
where  complications  were  present,  a  mortality  of  42-8  per  cent.  Of  57  am- 
putations iu  which  sepsis  was  already  present,  40  recovered,  and,  taking  all 
cases  without  distinction,  Oberst  collected  351  amputations  with  53  deaths,  or 
a  mortality  of  15'1  per  cent.,  and  849  per  cent,  recoveries.  Wolfier  has  given 
the  total  morttdity  of  amputations  occurring  in  Billroth's  clinic  as  19"7  per 
cent  In  uncomplicated  cases  the  mortality  was  5'7  per  cent.,  and  in  those  in 
which  complications  occurred— i.  e.,  in  amputations  where  sepsis  and  pyaemia 
were  already-  present — the  mortality  was  43"7  per  cent.  Essen  (in  Wahl's 
clinic)  gives  the  total  death  rate  as  179  per  cent.,  the  mortality  of  uncompli- 
cated cases  being  5  93  per  cent.,  and  of  those  with  complications  42'8  per  cent. 
The  mortality  of  the  255  amputations  performed  in  Czerny's  clinic  was  only 
2*7  per  cent.  (Schrade).  The  decrease  in  the  mortality  is  to  be  ascribed  solely 
to  the  aseptic  method  of  treating  wounds,  and  the  mortality  of  amputations 
and  disarticulations  would  be  still  less  if  all  the  operations  could  be  performed 
immediately  after  the  injury. 

§  39.  Artificial  Limbs. — The  substitution  of  artificial  limbs  for  lost 
extremities  has  become  more  and  more  common  in  recent  years.  In 
the  case  of  the  lower  extremity,  the  prothetic  apparatus  need  only  ren- 
der standing  and  walking  possible,  and  consequently  it  is  conceivable 
that  more  satisfactory  results  can  be  obtained  here  than  in  the  upper 
extremity,  where  the  manifold  movements  of  the  hand  and  fingers  can 
be  only  partially  supplied ;  and  not  every  one  is  in  a  position  to  pro- 


128         AMPUTATIONS,   DISARTICULATIONS,   AND  RESECTIONS. 

vide  himself  with  such  costly  apparatus  as  artificial  arms  and  legs,  with 
their  complicated  mechanism.  As  to  the  upper  extremity,  the  move- 
ments of  the  fingers  are  usually  imitated  by  spiral  springs,  or  springs 
are  placed  in  the  apparatus  in  such  a  way  as  to  make  the  latter  movable 
when  manipulated  by  the  other  hand  or  pressed  against  the  thorax  by 
the  stump,  etc.  The  simplest  and  cheapest  prothetic  apparatus  for  an 
amputated  arm  or  forearm  consists  of  a  leather  socket  in  which  the 
stump  is  placed  and  retained  by  straps.  At  the  other  or  lower  end  of 
the  piece  is  fastened  a  hook,  ring,  or  hand  carved  in  wood  and  covered 
by  a  glove.  It  is  remarkable  how  much  some  patients  can  sometimes 
accomplish  with  such  a  simple  apparatus. 

After  amputation  or  disarticulation  of  the  lower  extremity  we  make 
use  either  of  the  peg  leg  or  the  artificial  limb.  The  peg  leg  is  the  cheaper 
and  by  far  the  simpler  apparatus,  and  with  it  walking  is  generally  easier 
and  more  comfortable  than  with  the  artificial  limb.  Many  who  have 
long  been  tormented  by  the  latter  turn  finally  to  the  use  of  the  peg.  And 
it  is  worth  taking  into  consideration  that  the  peg  leg  can  be  repaired 
by  any  mechanic,  while  the  artificial  limb  requires  a  skilled  instrument- 
maker.  Trendelenburg  and  others  have  shown  that  the  peg  leg  can 
be  improvised  very  cheaply  by  fastening  a  stick  of  wood  to  a  socket 
made  of  pasteboard  by  means  of  a  water-glass  bandage.  The  artificial 
leg  is  usually  made  of  a  leather  pocket  in  which  the  stump  is  placed  ; 
to  this  is  joined  the  leg,  wliich  is  made  of  wood,  having  hinges  for  the 
knee  and  ankle  joints.  The  foot  can  be  extended,  when  pressing 
against  the  ground,  by  means  of  a  strong  spiral  spring.  The  move- 
ment of  the  knee  joint  is  accomplished  by  some  elastic  material  placed 
inside  the  leg;  and  simulatino-  the  function  of  the  muscles. 

In  a  case  of  low  amputation  of  the  leg,  A.  Bier  made  an  artificial 
foot  from  the  end  of  the  tibia  with  its  overlying  soft  jmrts  by  dividing 
the  bone  again  a  little  above  the  line  of  amputation  and  turning  the 
piece  so  that  it  would  unite  with  the  tibia  at  right  angles ;  the  lower 
portion  of  the  fibula  was  extirpated.  If  only  a  part  of  the  foot  is  lost 
the  defect  can  be  concealed  and  walking  rendered  possible  by  padding 
an  ordinary  boot  with  cotton.  These  brief  remarks  will  suflice  for  a 
general  understanding  of  the  principles  of  artificial  limbs. 

§  40.  Operations  on  Joints. — By  resection  of  a  joint  is  meant  the 
partial  or  complete  operative  removal  of  the  opposed  bony  surfaces 
forming  the  joint  by  means  of  the  saw,  sharp  spoon,  or  chisel.  A  dis- 
tinction is  made  between  partial  and  complete  resection,  depending 
upon  whether  the  ends  of  the  bone  are  completely  or  only  in  part 
removed.  If  the  joint  is  extensively  diseased,  we  do  not  satisfy  our- 
selves with  removal  of  the  bony  portion,  but  also  extirpate  the  synovial 


§40.]  OPERATIONS  ON  JOINTS.  129 

membrane — i.  c,  we  perform  a  complete  extirpation  of  tlie  joint.  In 
all  cases  in  which  the  j)ei"iosteuni  is  healthy  we  ))re.serve  it  on  account 
of  its  osteoplastic  power,  and  call  a  resection  of  this  kind  subperiosteal. 
A  distinction  is  made  between  eai-Iyand  late  resection  and  between  pri- 
mary, intermediate,  and  secondary  resection.  By  })riniary  resection  is 
meant  one  which  is  performed  innnediately  after  the  traumatism  has 
occurred  and  before  the  onset  of  inflammatory  reaction.  The  inter- 
mediate resection  is  performed  after  inflammatory  symptoms  appear, 
A  secondary  resection  is  one  performed  after  the  subsidence  of  the  in- 
flammatory reaction,  when  the  wound  is  granulating. 

Resection  of  Bones  in  Continuity. — Furthermore,  we  resect  bones  in 
their  conti unity  when  we  remove  greater  or  less  amounts  of  diseased 
portions  of  thein  by  means  of  the  chisel  or  saw  (Resection  of  Bones). 
The  removal  of  diseased  bone  by  the  sharp  spoon — for  example,  in 
tuberculosis — is  designated  as  a  scraping  out,  while  the  simple  division 
of  bone  in  its  continuity  is  called  osteotomy. 

Arthrectomy. — If  the  bony  parts  forming  the  joint  are  left  intact, 
and  only  the  diseased  synovial  membrane  of  the  joint  is  removed,  as  in 
tuberculosis,  the  operation  is  an  arthrectomy.  The  simple  opening  of 
the  joint  is  called  arthrotomy.  We  shall  confine  ourselves  here  to  the 
general  technique  of  joint  resections,  and  shall  take  up  the  resections 
of  particular  joints  in  the  Special  Surgery. 

Indications  for  Resection  of  a  Joint. — The  indications  for  resecting:  a 
joint,  especially  for  performing  total  resection,  have  become  much 
fewer  in  number  since  the  introduction  of  antiseptic  surgery.  At  the 
present  time  we  are  often  able  to  save  a  joint — one,  for  instance,  which 
has  been  laid  open  by  a  wound — where  formerly  it  would  have  been 
sacrificed.  AVe  now  go  on  the  principle  of  performing  a  resection  as 
conservatively  as  possible — i.  e.,  we  try  to  preserve  as  much  of  the 
articular  surfaces  of  the  bone  as  we  can.  The  complete  resection  of 
joints  in  children,  which  used  to  be  so  frequently  performed  for  tuber- 
culosis, should  be  entirely  given  up.  In  these  cases  we  should  be  satis- 
fied with  removing  the  diseased  portion  of  the  bone  with  the  sharp 
spoon  or  the  chisel,  with  the  single  exception  of  the  hip  joint ;  and  in 
adults  the  use  of  total  resection  should  be  restricted  as  much  as  possible, 
and  as  much  bone  saved  as  possible.  If  only  the  capsule  of  the  joint  is 
diseased — as,  for  example,  in  tuberculosis — only  this  should  be  extirpated 
(arthrectomy),  and  the  bony  portion  of  the  joint  should  be  left  intact. 
When  arthrectomy  is  performed — for  instance,  at  the  knee  in  a  case  of 
synovial  disease — a  movable  joint  may  be  obtained  (Angerer.  Sendler, 
myself,  and  others).  On  the  other  hand,  it  cannot  be  denied  that  a 
very  good  functional  result  is  possible  after  an  extensive  atypical  resec- 
10 


130         AMPUTATIONS,   DISARTICULATIONS,   AND   RESECTIONS. 


tioDj  as  in  the  case  of  tlie  foot,  and  amputation  be  thus  avoided.  I 
agree  with  Ivappeler,  Mikulicz,  Kiister,  and  others  in  sanctioning 
extensive  atypical  resections,  particularly  of  the  foot. 

In  general,  resection  of  a  joint  is  indicated  after  severe  injuries 
(traumatic  resection)  and  for  pathological  changes  in  the  joint  (patho- 
logical resection).  Among  injuries  of  a  joint  calling  for  resection  are 
(1)  compound  fractures  involving  the  joint,  with  considerable  splinter- 
ing of  the  bones,  especially  gunshot  fractures ;  also  dislocations  accom- 
panied by  rupture  of  the  skin  and  overlying  parts.  Since  the  intro- 
duction of  antisepsis  it  will  often  be  found  sufficient  in  these  cases  to 
drain  the  joint  thoroughly  after  reducing  the  dislocation  or  removing 
whatever  loose  fragments  are  entirely  detached.  Resection  of  a  joint 
is  also  called  for  (2)  when  there  is  very  extensive  suppuration  or  violent 
inflammation  in  tlie  joint  after  an  injury,  and  especialh'  when  there  is 
(3)  chronic  disease  of  the  joint,  tuberculosis  being  the  most  common. 
Resections  may  also  be  performed  for  (4)  loss  of  function  in  a  joint 
caused  by  contractures  or  anchylosis,  and  in  old  dislocations  in  which 
there  is  a  malposition  of  the  bones  which  interferes  with  the  functions 
of  the  joint,  or  in  which  the  head  of  the  bone  presses  on  nerves  and  ves- 
sels, and  finally  (5)  for  new  growths  in  the  bones. 

Osteoclasis,  or  subcutaneous  fracture  of  bones  by  the  osteoclast 
(Molliere),  has  of  late  years  been  used  very  largely  in  place  of  the  so- 
called  orthopaedic  resections  for  improving  deformities  of  bone.  But  I 
agree  with  Oilier,  that  osteoclasis  is  not  always  as  effective  as  its  in- 
ventor claims ;  and,  furthermore,  it  is  not  always  possible  to  break  the 

bones  at  precisely  the  desired  point 
and  without  damaging  the  soft  parts. 
Osteoclasis  cannot  usually  be  em- 
ployed in  cases  of  anchylosis. 

General  Rules  for  performing  Re- 
section.— The  operation  of  resecting 
a  joint  is  divided  into  three  stages : 
(1)  The  incision  through  the  soft 
parts ;  (2)  opening  the  joint ;  (3) 
division  and  removal  of  the  injured 
or  diseased  ends  of  the  bones  with 
or  without  extirpation  of  the  syno- 
vial membrane.  AVhen  possible,  the 
operation  should  be  performed  with 
the  aid  of  Esmarch's  artificial  ischae- 
mia,  and  of  course  with  the  strictest  aseptic  precautions.  The  soft  parts 
are  divided  with  a  short,  strong  knife  (Fig.  107).     Resection  knives  are 


FiG.lOT. — Eeseotion  knives 


t5  40.]  OPERATIONS   ON   JOINTS.  131 

sometimes  pointed,  sometimes  l>luiit,  or  fitted  with  a  prol)e  point.  The 
incision  througli  the  soft  purts  is  mude  })i'efenihly  in  tiie  hjn<5axisof  the 
limb,  because  this  involves  tlie  least  injury  to  muscles  and  tendons  at 
their  point  of  insertion,  as  well  as  to  vessels  and  nerves.  Oidy  in  the 
ease  of  the  knee — and,  under  certain  conditions,  the  ankle — are  trans- 
verse incisions  allowable  for  affording  a  better  view  of  the  diseased  joint. 
The  joint  is  opened  in  the  line  of  the  cutaneous  incision.  It  is  very  im- 
l)ortant  for  the  future  function  of  the  joint  to  preserve  the  tendinous 
insertions  of  the  muscles  about  the  joint  and  to  keep  intact  their  con- 
nection, as  well  as  that  of  the  capsule  with  the  periosteum.  In  all  cases 
where  the  periosteum  is  healthy,  as  in  pritnary  traumatic  resections,  it 
should  be  preserved — i.  e.,  a  subperiosteal  i-esection  should  be  performed. 
If  it  is  diseased,  it  must  of  course  be  removed,  as  well  as  the  bone.  If 
the  periosteum  is  to  be  retained — that  is,  if  we  are  going  to  do  a  sul)peri- 
osteal  resection — it  is  divided  in  the  line  of  the  cutaneous  incision  and 
raised  by  the  raspatory  (Fig.  63)  and  periosteal  elevator  (Fig.  64).  At 
those  places  where  the  periosteum  becomes  continuous  with  the  capsule, 
muscular  insertions,  and  ligaments,  it  must  be  sejDarated  from  the  bone 
by  perpendicular  or  horizontal  strokes  of  the  knife. 

Vogt  and  Konig  have  introduced  an  excellent  plan  for  retaining 
the  connection  of  the  muscular  insertions  to  the  bony  protuberances  to 
which  they  are  attached.  These  protuberances  are  separated  from  the 
shaft  of  the  bone  by  the  hammer  and  chisel,  or,  in  the  case  of  children, 
by  the  knife,  and  at  the  conclusion  of  the  operation  they  are  again 
brought  back  into  place  and  secured  by  means  of  silver  wire  or  nails. 
When  there  is  a  tubercular  panarthritis,  or  when  diseased,  it  would  of 
course  be  a  mistake  to  preserve  the  periosteum.  In  such  cases  the 
joint  must  be  entirely  extirpated — i.  e.,  all  diseased  soft  parts  and  bone 
must  be  removed. 

The  periosteum  having  been  removed,  or  left  in  place,  as  the  case 
may  be,  the  next  step  is  the  division  of  the  bone  (see  §  26).  Tlie  ends 
of  the  bone  are  forced  out  of  the  wound,  while  the  soft  parts  are  held 
aside  by  retractors,  or  the  bony  parts  are  divided  in  situ  with  the  meta- 
carpal, bow,  or  chain  saw,  or  with  the  chisel.  The  bones  of  children 
can  be  cut  with  the  knife.  After  division  of  the  bone  all  projecting 
angles  are  levelled  off. 

If  anchylosis  is  desired — for  example,  in  the  case  of  the  knee — the 
ends  of  the  bones  are  fastened  together  with  catgut,  silver  wire,  or 
four-cornered  steel  nails  which  have  been  carefully  disinfected  (see 
also  §  34).  Since  partial  resections  give  in  general  a  better  func- 
tional result  than  total  ones,  the  former  should  be  given,  when  possil)le, 
the  preference  in  all  joints  in  which  we  wish  to  obtain  motion.     The 


132         AMPUTATIONS,   DISARTICULATIONS,   AND   RESECTIONS. 

strictest  asepsis  must  be  maintained  in  all  stages  of  the  operation.  At 
its  conclusion  the  h8emorrhage  must  be  arrested  with  the  utmost  care, 
drainage  of  tlie  joint  must  be  provided  for,  and,  after  suturing  the 
wound  and  applying  an  antiseptic  dressing,  the  joint  must  be  immo- 
bilised by  a  suitable  splint.  If  the  operation  is  performed  with  artifi- 
cial ischfemia,  it  is  best  to  remove  the  elastic  cord  and  arrest  the  bleed- 
ing before  suturing. 

In  case  of  extensive  suppuration  of  a  joint,  or  advanced  tubercular 
disease,  the  wound  should  not  be  closed  with  sutures,  but  packed  with 
iodoform  gauze  or  sterilised  compresses.  When  only  a  few  interrupted 
sutures  are  inserted  and  the  wound  is  left  partially  open,  drainage  may 
be  dispensed  with.  If  no  reaction  follows,  a  plaster  dressing  can  be 
placed  over  the  antiseptic  dressing  after  a  few  days. 

For  the  method  of  dressing  individual  joints  after  resection,  refer- 
ence is  made  to  the  text-book  on  special  surgery. 

Outcome  of  Resections  of  Joints. — The  results  of  joint  resection  are 
either  anchylosis,  or  an  actively  movable  joint,  or  a  so-called  flail-like 
joint.  In  the  lower  extremity,  at  the  knee  and  ankle,  anchylosis  is  the 
most  desirable  result.  In  "the  hip  and  upper  extremity  a  movable 
joint  is  preferable.  For  restoring  the  function  of  a  joint  after  the 
wound  has  healed,  the  after-treatment  is  of  great  importance.  It  is 
possible  to  obtain  very  excellent  results  by  the  methodical  use  of  active 
and  passive  motion,  by  electricity,  massage,  and  baths.  If  anchylosis  is 
desired,  the  joint  should  be  immobilized  in  the  position  which  is  most 
suitable  for  subsequent  use,  by  means  of  a  plaster  dressing  or  a  splint 
left  in  place  for  a  considerable  length  of  time  (see  Methods  of  Dress- 
ing, and  the  special  surgery).  If  a  flail-like  joint  is  obtained,  it  must 
be  re-enforced  by  a  suitable  supporting  apparatus,  or  another  operation 
must  be  done  to  obtain  anchylosis  (see  Arthrodesis,  below). 

The  causes  of  death  following  resection  are  the  infectious  wound 
diseases,  such  as  sepsis  or  pysemia,  due  to  imperfect  asepsis,  or  to  their 
presence  at  the  time  of  the  operation.  Patients  who  have  undergone 
this  operation  sometimes  die  from  fat  emboli,  especially  when  there  is 
advanced  fatty  degeneration  of  the  bone  marrow.  P.  Vogt  has  very 
properly  advised  that  bones  in  which  there  is  this  fatty  degeneration 
should  not  be  joined  together  too  closely. 

History  of  Resections. — Resections  were  performed  in  the  flourishing 
days  of  surgery  at  the  time  of  the  Roman  Empire,  but  were  forgotten  entire- 
ly during  the  middle  ages,  and  were  not  again  systematically  practiced  till 
near  the  close  of  the  eighteenth  century.  In  England,  White  was  the  first 
to  use  the  operation,  performing  a  resection  of  the  humerus.  In  France  the 
operation  was  employed  by  Moreau;   later  by  Sabatier,  Percy,  Dupuytren, 


i;4o.]  opp:rations  on  joints.  133 

and  Larry.  Von  Tcxtor,  B.  von  Jiijjer,  and  Ried  introduced  the  operation 
ainon;?st  German  surgeons.  Langenbeck  has  done  more  than  anybody  to 
advance  the  techni(iue  of  joint  resection. 

Arthrodesis. —  l>y  iirthrudesis  is  understood  the  artificial  anchylosis 
i>f  a  tluil-like  joint — in  cases  of  ])arulysis,  for  example,  in  which  it  was 
first  practiced  by  Albert,  who  operated  M'ith  excellent  results  on  both 
knee  joints  of  a  young  girl  sulfei-ing  from  ])aralysis  of  the  lower 
extremities.  The  oj)eration  is  very  useful,  especially  for  paralytic 
tlail-like  joints.  At  first  arthrodesis  was  frequently  performed  by 
fastening  the  bones  together  with  a  wire  suture  after  a  typical  resec- 
tion of  their  joint  surfaces.  But  it  is  a  better  plan  to  pare  off  onlv 
the  articular  cartilages,  and  then  unite  the  bones  with  long,  perfectly 
sterilised  steel  nails  instead  of  the  silver-wire  suture.  The  synovial 
mendjrane  should  be  allowed  to  remain  intact.  If  healing  takes  place 
with  some  slight  amount  of  suppuration,  the  synostosis  of  the  joint 
ends  of  the  bones  is  more  solid  than  if  the  wound  unites  by  primary 
union  (Zinsmeister).  II.  Euringer  has  collected  from  literature  sixty- 
eight  cases  of  arthrodesis  (in  fifty  patients),  of  which  the  majority  were 
successful,  and  enabled  the  patients  to  dispense  with  the  heavy,  uncom- 
fortable, and  expensive  splint  apparatus. 


CHAPTER  X. 

OPERATIONS    FOR    REMEDYING    DEFECTS    IN    THE    TISSUES. PLASTIC 

OPERATIONS. — TRANSPLANTATION. 

Plastic  operations  for  loss  of  substance  in  the  skin. — General  methods  of  plastic  sur- 
gery in  case  of  loss  of  substance  in  the  skin :  niovability  of  skin ;  liberating 
incisions;  formation  of  flaps  with  pedicles;  implantation  of  entirely  separated 
portions  of  skin. — Skin-grafting  by  the  methods  of  Reverdin  and  Thiersch. — 
Grafts  of  skin  or  mucous  membrane  taken  from  animals. — Hair-grafting. — Plastic 
operations  for  defects  in  other  tissues  (muscles,  tendons,  nerves,  bones). 

§  41.  Plastic  Operations  for  Cutaneous  Defects. — If  the  loss  of  sul)- 
stance  in  the  tissues  is  so  great  that  it  cannot  be  reiiiedied  by  simply 
suturing  together  the  borders  of  the  wound,  we  perform  what  has 
been  called  by  the  general  name  of  a  plastic  operation,  for  remedying 
the  defect  or  bringing  about  a  more  rapid  cicatrisation. 

IVe  shall  first  take  up  the  operative  treatment  of  loss  of  substance 
in  the  skin.  These  defects  are  either  fresh  and  the  result  of  an  injury 
or  an  operation,  or  they  are  old  or  congenital,  or  made  up  of  a  granu- 
lating wound  surface.  For  treating  such  defects  in  the  skin,  or  for 
hastening  cicatrisation,  there  are  in  general  two  principal  methods : 

1.  The  closure  of  the  defect  by  traction  upon  the  skin  in  the  neigh- 
bourhood, and  by  the  formation  of  a  cutaneous  flap,  which  is  freed 
from  the  underlying  parts  in  such  a  way  that  it  still  possesses  a  bridge 
of  skin  at  some  portion  of  its  circumference,  called  a  pedicle,  connect- 
ing it  with  the  neighbouring  skin. 

2.  The  defect  is  also  remedied  by  the  transplantation  or  implanta- 
tion of  an  entirely  detached  portion  of  skin.  This  latter  method  has 
been  perfected  by  Thiersch,  and  is  now  very  frequently  used  for  plac- 
ing an  epidermic  covering  over  a  fresh  or  granulating  defect  in  the 
skin  or  mucous  membrane  (see  page  141).  The  first  method,  in  which 
the  defect  is  remedied  by  traction  on  the  surrounding  skin  and  by  the 
foriuation  of  a  movable  flap  with  a  pedicle,  is  what  is  ordinarily  meant 
by  a  plastic  operation,  but  it  has  been  largely  supplanted  bj'  Thiersch's 
method  of  skin  transplantation  or  skin  grafting. 

Defects  not  only  in  the  skin,  but  also  in  muscles,  tendons,  nerves, 

(134) 


^41,]  PLASTIC  OPERATIONS  FOR  CUTANEOUS   DEFECIS.  135 

and  bone,  can  he  remedied  by  plastic  operations — i.  e.,  by  the  forma- 
tion of  Haps  witli  pedicles  or  by  the  transplantation  of  j)()rtions  of  tissue 
entirely  se[)arated  from  their  original  surroundings. 

Modern  asej)tic  surgery  has  made  great  advances  in  plastic  opera- 
tions and  in  the  grafting  of  diiferent  tissues  on  others.  Portions  of 
tissue,  such  as  bone,  nerve,  or  skin,  which  have  been  completely  severed 
from  the  body,  will  only  unite  in  their  new  position  when  no  supi)u- 
ration  occurs,  and  it  is  consequently  of  the  greatest  importance  that 
there  should  be  ])rimary  union. 

The  cutaneous  defects  in  which  plastic  operations  are  called  for  are 
caused  by  injuries  and  by  diseases  of  every  description  (wounds  from 
freezing,  burning,  inflammation  causing  necrosis,  operations  for  tu- 
mours, malformations  like  harelip,  ectopia  vesicae,  etc.).  Plastic  opera- 
tions are  also  indicated  in  cicatrices  causing  deformity  or  loss  of  func- 
tion in  a  part.  German  surgeons  especially — Griife,  Dieffenl)aeli,  Lang- 
enbeck,  Konig,  Thiersch,  and  others — have  devoted  themselves  to  ad- 
vancing the  methods  for  performing  plastic  operations.  The  ancient 
surgeons,  particularly  in  India,  were  skilled  in  this  branch,  having 
plenty  of  opportunity  for  performing  rhinoplasty  and  otoplasty,  on  ac- 
count of  the  frequency  of  the  form  of  punishment  which  consisted  in 
cutting  off  the  nose  or  ears. 

The  Healing  in  Place  again  of  a  Completely  Severed  Portion  of  Tissue. 
— If  small  portions  of  the  body,  like  the  tips  of  the  lingers  or  the  nose, 
are  completely  cut  off,  they  will  sometimes  reunite  in  their  proper  posi- 
tion by  primary  union  if  they  are  carefully  sutured  in  place  with  ev'ery 
antiseptic  precaution,  provided  the  piece  of  tissue  is  not  too  large 
and  not  too  much  crushed,  and  the  sutures  are  applied  immediately 
after  the  receipt  of  the  injury.  We  shall  return  to  the  subject  of  the 
reuniting  of  small,  completely  severed  portions  of  tissue  in  the  chapters 
on  Injuries  and  the  Repair  of  Wounds. 

As  to  the  time  when  plastic  operations  should  be  performed,  we 
have  stated  that  they  may  be  done  at  once  on  a  fresh  wound,  immedi- 
ately after  the  termination  of  an  operation  like  the  removal  of  a  cancer 
from  the  lip,  or  as  one  of  the  steps  in  operating  on  harelip,  etc. ;  or,  on 
the  other  hand,  on  a  granulating  surface.  If  the  loss  of  substance  in 
the  skin  is  due  to  a  crushing  wound,  we  should  wait  until  it  can  be  defi- 
nitely determined  how  much  of  the  crushed  tissue  will  survive.  When 
a  granulating  wound  is  to  be  covered  with  a  cutaneous  flap  having  a 
pedicle,  it  is  best  to  change  the  granulating  surface  into  a  fresh  wound 
by  scraping  or  cutting  off"  the  granulation  tissue,  and  upon  this  surface 
to  engraft  the  skin  flap.  On  the  other  hand,  granulating  skin  flaps  can 
be  safely  transplanted,  for  example,  on  to  a  defect  in  the  anterior  wall 


136     OPERATIONS   FOR   REMEDYING   DEFECTS  IN  THE  TISSUES. 

of  the  bladder  (ectopia  vesicse).  It  has  ah-eady  been  mentioned  that  in 
other  cases  we  are  able  to  perform  plastic  operations  after  actual  cica- 
trization of  the  wound  has  taken  place,  or  after  extirpation  of  a  scar 
which  is  nnsightly  or  interferes  with  the  function  of  a  part. 

General  Principles  of  Plastic  Surgery. — The  following  is  a  brief  state- 
ment of  the  general  principles  governing  plastic  sui-gerj,  the  details  of 
which  for  special  plastic  operations — such  as  rhinoplasty,  cheiloplasty, 
the  operations  for  ectopia  vesicse,  etc. — will  be  considered  in  the  text- 
book on  special  surgery. 

It  is  of  the  greatest  importance  for  the  success  of  any  plastic  opera, 
tion,  or  for  the  union  of  a  skin  Hap  in  its  new  bed,  that  the  operation 
should  be  conducted  with  the  strictest  attention  to  asepsis.  The  bor- 
ders of  the  wound  should  be  as  smooth  and  sharply  outlined  as  possible, 
the  flaps  should  be  cut  of  adequate  size,  not  too  small  or  too  thin,  and 
the  subcutaneous  fatty  tissue  should  be  preserved  in  its  connection  with 
the  flap.  The  sutures  should  be  of  catgut  or  line  aseptic  silk,  and 
should  be  so  applied  that  the  borders  of  the  wound  are  held  in  exact 
apposition. 

Coaptation  of  the  Borders  of  the  Wound  and  Freeing  of  the  Skin 
from  Underlying  Parts. — The  simplest  way  of  closing  a  defect  in  the 
skin  consists  in  drawing  together  the  borders  of  the  wound  and  uniting 
them  with  sutures.  To  render  the  edges  of  skin  more  movable,  they 
can  be  dissected  free,  together  with  the  attached  subcutaneous  fat,  from 
the  underlying  parts.  Thus  cutaneous  defects  of  the  most  diverse 
shapes,  if  not  too  large,  may  be  easily  closed,  as  illustrated  in  Fig.  108. 

Julius  Wolff 
Y  has        recently 

I  elaborated   this 

b  method  of  clos- 

FiG.  108. — Union  of  the  bol■der^^  of  an  area  where  there  has  been  a  loss  of  jj-)o-    defects    by 

substance  in  the  skin  ;  the  ed>fe.s  of  the  skin  are  treed  from  the  un-  ^     .                     "^ 

derlyin^  parts  and  united  by  sutures:    «,  before  inserting  the  su-  drawing       OVCr 

tares;  6,  after  insertintf  the  sutures.  ^                ^              -i 

tiiem  the  ad- 
joining skin,  which  has  first  l)een  freed  from  the  subjacent  parts,  and 
then  suturing  the  edges  of  the  skin.  He  has  in  this  way  closed  large 
areas  where  loss  of  sul)stance  has  occurred  in  skin  and  in  bone,  and  has 
also  applied  it  to  widely  opened  joints.  The  skin  is  loosened  for  some 
distance  around  the  wound,  partly  with  the  hand  and  partly  with  a 
probe-pointed  knife  or  scissors,  and  then  brought  over  the  wound  and 
sutured  (Berlin,  klin.  Wochenschr.,  1890,  No.  6). 

In  other  cases  it  is  best  to  make  use  of  lateral  liberating  incisions  ; 
i.  e.,  before  or  after  inserting  the  sutures  in  the  approximated  margins 
of  the  wound,  an  incision  is  made  parallel  to  and  at  one  side  of  the  su- 


«44 


J5  41. 


PLASTIC   OPKIIATIOXS   FOR   CUTANEOUS  DEFECTS. 


137 


Fig.  109.— Lateral  liberatinfr  incisions:  a, 
before  in.sertinfr  the  sutures;  6,  after 
inserting  the  sutures. 


tiire  lino,  in  ordcM-  to  lessen  the  tension  on  tlie  suture  line  (Fig.  109,  a). 
As  illustrated  in  Fig,  109,  J,  the  liberating  incisions  cause  slightly  gap- 
ing wounds  after  the  defect  has  hecn 
closed,  hut  these  usually  heal  raj)idly  I)y 
asej)tic  granulation. 

In    a   third  categoi'j    of   cases   the 
skin  is  drawn  over  a  defect  after  mak- 
ing one  or  more  incisions  prolonged 
from  the  limit  of  the  original  defect  in 
any   required    direction,    and    by    this 
means  forming  a  kind  of  flap.     This  is 
only  a  modification  of  the  method  of 
closing  a  defect  by  sliding  the  skin  over  it.  and  does  not  belong  to  the 
imj)ortant  method  of  plastic  surgery  about  to  be  described — namely, 
the  formation  of 
a  flap  with  a  ped- 
icle. In  Figs.  110, 
111,  and  112  are 
seen  examples  of 
the  appilication  of 
this  method.     In 
Fig.       110,      the 
original    incision 

has  been  prolonged  in  the  line  c  d,  and  the  portion  of  skin  a  c  d  is 
thus  rendered  capable  of  being  moved,  c  being  drawn  over  to  b,  and  the 
two  borders  of  the  defect  are  united  with  sutures,  giving  the  result 
illustrated  in  Fig.  110,  h.  In  the  same  manner,  under  other  circum- 
stances, a  second  incision  can  be  prolonged  from  the  original  defect  at  b. 
When  the  three-cornered  defect  is  closed  by  sutures  there  results  some 
slight  puckering  of  the  skin  at  the  sides.     Burow  remedies  this  by  ex- 


I  r  HiTir- 


Fig.  110. 


-Incision  prolonored  from  one  corner  of  a  triangular  wound  ; 
a,  before,  and  b,  after  inserting  the  sutures. 


h,]]  \  ]  \I 


d 


Fig.  111. — Curved  incision  from  one  comer  of  a  triangular  wound  :  a,  before;  b,  after  inserting 

the  sutures. 


cising  small  three-cornered  portions  of  skin  in  this  region.     This  plan 
of  excising  a  triangular-shaped  portion  of  tissue,  which  Burow  intro- 


138    OPERATIONS   FOR  REMEDYING   DEFECTS   IN    THE  TISSUES. 

duced,  is  at  present  but  little  used.     In  Fig.  Ill  the  liberating  incision 
c  di&  prolonged  from  the  edge  of  the  defect  in  a  curved  direction,  and 


4  n  [  y  n  H^ 


4  1  i  i  n  i  1 11' 

a  b 

Fig.  112. — Prolonged  Incisions  for  uniting  a  four-cornered  wound  :  a,  before;  J,  after  inserting 

the  sutures. 

here  also  a  second  curv^ed  incision  from  h  can  be  employed  with  advan- 
tage for  closing  the  defect  by  sliding  over  it  a  portion  of  the  adjoining 
skin.  In  Fig.  112  four  lateral  incisions  are  made  for  closing  a  quadri- 
lateral defect.  This  principle  of  making  lateral  incisions  or  prolonging 
the  original  incisions,  followed  by  drawing  the  skin  over  the  defect,  is 
capable  of  almost  endless  variations. 

Formation  of  Flaps  with  Pedicles. — The  most  important  method 
Ufjcd  in  plastic  surgery  consists  in  fashioning  flaps  which  have  a  pedicle 
— i.  e.,  cutaneous  flaps  which  remain  connected  with  their  original  local- 
ity in  the  skin  by  means  of  a  bridge  or  pedicle  through  which  they  are 
nourished,  but  throughout  all  the  rest  of  their  extent  they  are  com- 
pletely separated  from  their  original  bed.     After  this  has  been  done 


^^^'M  u  r 


eVi\ 


t-t 


^-e 


Fig.  113.— Formation  of  two  lateral  flaps  of  skin  :  a,  before  ;  6,  after  inserting  the  sutures. 

the  flap  is  laid  in  the  defect,  as  illustrated  in  Fig.  113,  h.  In  Fig.  113 
two  lateral  flaps  are  fashioned  (Fig.  113,  a)  and  placed  in  the  defect 
(Fig.  113),  so  that  Fig.  113,  c,  results  when  the  edges  of  the  wound  are 
united  by  sutures.  In  Fig.  114,  a  c,  is  illustrated  the  method  of  per- 
forming a  complete  rhinoplasty.  For  details  and  other  methods  of 
performing  rhinoplasty  reference  is  made  to  the  Special  Surgery. 

When  flaps  with  pedicles  are  used  care  must  be  taken  that  the 
blood  supply  is  good  and  that  primary  union  is  obtained.  The  pedicle 
must  be  so  situated  that  as  many  vessels  as  possible  enter  the  flap ;  and 
the  pedicle  must  not  be  too  narrow  or  too  thin.  The  flap,  particularly 
the  portion  constituting  the  pedicle,  is  freed  with  every  precaution  for 


g41.] 


PLASTIC  OPERATIONS   P\JIl  CUTANEOUS   DEFECTS. 


139 


preventing  its  beconiing  too  tliin.     Moreover,  it  is  important  that  tlie 
part  representing  the  pedicle  should  not  he  subject  to  too  nuicli  ten- 


FiG.  114. — Rhino-plasty  :  a,  freshcnino:  of  tlie  borders  of  the  defect  in  the  skin,  and  formation  of 
the  pear-shaped  Hap  on  the  forehead ;  6,  after  placing  the  Hap  over  the  defect  in  the  skin ; 
c,  Langenbeck's  method  for  performing  rJiino-phisty. 

sion  when  the  flap  is  implanted  on  the  defect,  for  otherwise  the  nutri- 
tion might  be  materially  impaired. 

j  Plastic  surgery  performed  with  flaps  having  a  pedicle  was  the  form 
in  which  it  was  especially  used  by  Indian  surgeons,  and  they  probably 
originated  it. 

Flaps  have  also  been  fashioned  from  portions  of  the  body  widely 
separated  from  the  defect,  as  we  shall  see 
when  we  take  up  rhinoplasty.  Tagliacozzi 
(Taliacotius,  1597),  a  physician  of  Bologna 
living  in  the  sixteenth  century,  was  the  first 
to  use  a  flap  fashioned  from  the  skin  in  the 
biceps  region  of  the  arm,  and  after  placing 
the  arm  over  the  nasal  defect  and  allowing 
the  flap  to  heal  into  the  latter,  he  cut  the 
flap  loose  by  dividing  its  pedicle  (Fig.  115). 
This  Italian  method,  as  it  is  called,  is  only 
applicable  to  those  exceptional  cases  in 
which  good  material  for  making  the  flap 
cannot  be  obtained  in  the  neighbourhood  of 
the  defect.  The  Italian  method  is  usually 
performed  in  three  stages  :  (1)  The  forma- 
tion of  a  flap  which  remains  attached  by  two  pedicles ;  the  flap  is  sepa- 
rated from  the  underlying  parts  after  making  two  lateral  incisions,  and 
its  reunion  prevented  by  iodoform  gauze  or  oiled  silk  placed  under 


Fig.  115. — Italian  method  of  per- 
forming rhino-plasty  (Taglia- 
cozzi and  Graefe). 


liO     OPERATIONS   FOR  REMEDYING   DEFECTS   IN   THE   TISSUES. 

the  flap.  (2)  After  gmnulation  has  become  well  estahlished  one  pedicle 
is  divided,  and  the  Hap  is  sutured  into  the  defect  (Fig.  115).  (3)  After 
the  flap  has  healed  into  its  new  bed,  or  after  eight,  ten,  or  fourteen 
days,  the  other  bridge  of  skin  or  pedicle  is  divided.  Graefe  has  per- 
formed the  Italian  method  in  one  sitting  by  bringing  the  flap  directly 
in  contact  with  the  defect  (the  German  method).  But  the  nutrition  of 
the  fresh  flap  is  often  poor,  and  it  is  likewise  very  apt  to  shrink. 

In  recent  times  this  method  of  remedying  defects  by  transplanta- 
tion of  pedunculated  flaps  from  distant  portions  of  the  body  has  been 
revived,  and  fresh  flaps  of  this  kind,  taken,  for  example,  from  the  tho- 
rax, have  been  transplanted  to  fresh  and  granulating  defects  in  the 


\?i^ 


Fi«.  116, — The  manner  of  remedyinsr  losses  of  substance  at  the  bend  of  the  elbow,  and  on  the 
forearm  by  pedunculated  flaps  of  skin  from  the  thorax:  a,  pedunculated  flap  of  skin  which 
still  remains  attached  to  tlie  thorax,  and  which  has  been  sutured  into  the  defect;  J,  after 
it  has  healed  in  place. 

arm  and  forearm,  and  have  thus  prevented  contractures  of  the  elbow 
joint  after  burns,  avulsion  of  the  skin,  etc.  (Maas,  Langenbeck's  Archiv, 
Bd.  xxxi ;  Wagner,  ibid.,  Bd.  xxxvi,  1887,  S.  381  ;  and  Y.  Hacker, 
Bd.  xxxvii). 

Granulating  Skin  Flaps. — Xot  only  fresh  but  also  granulating  skin 
flaps  are  used,  as  we  have  seen,  especially  for  closing  congenital  defects 
in  the  bladder  (ectopia  vesicae).  (See  Special  Surgery.)  For  closing 
a  defect  in  the  wall  of  a  cavity,  as  in  ectopia  vesicae,  and  defects  in  the 
cavity  of  the  mouth  following,  for  example,  the  removal  of  a  cancer, 
Blessing  has  recommended  the  use  of  flaps  covered  with  epidermis. 
After  fashioning  a  skin  flap  with  a  pedicle,  its  wound  surface  is  pro- 
vided with  epidermis  by  Thiersch  skin  grafts  (see  p.  1-11),  and  then  the 
graft  is  allowed  to  heal  into  the  defect. 

Skin  Flaps  with  a  Pedicle  of  Subcutaneous  Tissue — Gersuny's  Meth- 


g42.]  SKIN-GRAFTING  ACCORDING  TO  Rl^:VERDlN  AND  THIERSCH.    141 

od. — Gersniiy  was  the  first  to  show  tliat  a  skin  flap  whicli  possessed 
only  a  pedicle  of  subcutaneous  tissue  would  receive  sufficient  nourish- 
ment to  enable  it  to  be  used  for  plastic  purposes,  jiarticularly  in  reme- 
dying defects  of  mucous  membrane.  The  flap  is  simi)ly  turned  into 
the  defect  like  a  door  on  its  hinges,  or  it  is^-^rawn  into  a  more  deep- 
ly lying  region  through  a  suital)ly  placed  slit  or  wide  button-hole. 

Transplantation  of  entirely  severed  Pieces  of  Skin, — Moreover,  pieces 
of  skin  which  have  been  entirrhj  scpdrdtt'd  from  their  original  hed 
can  be  implanted  in  defects.  ^Vecker  and  others  have,  in  the  case  of 
defects  of  the  lower  eyelid  (ectropion),  successfully  implanted  a  single 
flap  of  skin  which  did  not  even  possess  a  pedicle.  This  method  has 
been  long  practiced  by  the  Indian  surgeons,  luit,  in  spite  of  even  the 
present  aseptic  way  of  doing  this,  it  is  still  a  matter  of  uncertainty 
whether  a  portion  of  skin  which  includes  the  entire  thickness  of  the 
cutis  will  heal  into  its  new  position.  To  Reverdin  and  to  Thiersch 
especially  belong  the  credit  of  having  given  a  practical  surgical  im- 
portance to  the  method  of  transplanting  portions  of  skin  entirely 
severed  from  their  original  !)ed. 

§  42.  Skin-grafting  according  to  E6verdin  and  Thiersch. — In  1870 
Reverdin  used  his  method  of  epidermic  or,  more  correctly,  skin-epider- 
mic grafting  for  causing  a  granulating  M'ound  to  skin  over  more  rap- 
idly than  it  otherwise  could,  as  a  granulating  wound,  in  whicli  the 
corium  is  entirely  absent,  can  only  become  covered  with  skin  by  a  very 
gradual  ingrowth  of  the  latter  from  the  edges.  It  is  only  possible  for 
skin  to  start  to  grow  outwards  from  the  middle  of  a  granulating  sur- 
face when  there  still  remains  in  this  area  remnants  of  the  rete  Malpighii 
or  of  the  sebaceous  glands.  By  Reverdin's  skin-grafting  not  only  is 
the  length  of  time  required  for  a  wound  to  skin  over  shortened,  but 
the  subsequent  cicatricial  contraction  is  considerably  diminished.  The 
way  in  which  Reverdin  originally  practiced  this  was  very  imperfect, 
and  Thiersch  was  the  first  to  develop  a  useful  and  satisfactory  method 
of  skin-grafting  or  skin-transplantation.  The  skin  is  applied  to  a  fresh 
defect  after  the  bleeding  has  been  thoroughly  arrested  ;  but  if  the  de- 
fect consists  of  an  old  granulating  surface  the  granulation  tissue  must 
be  first  removed  with  the  knife  or  sharp  spoon.  Nevertheless,  skin 
can  also  be  transplanted  on  to  a  granulating  surface,  especially  in  the 
case  of  a  granulating  area  of  bone.  Moreover,  skin  for  transplanting 
purposes  can  be  taken  from  a  fresh  cadaver  before  the  onset  of  rigor 
mortis,  and  from  a  part  which  has  just  been  amputated,  etc. 

Thiersch's  Method  of  Skin-grafting. — The  instruments  to  be  used  are 
sterilised  by  boiling  them  for  about  five  minutes  in  a  one-per-cent.  soda 
solution  and  are  then  placed  in  a  sterilised  six-tenths-per-cent.  solution 


142     OPERATIONS  FOR   REMEDYING   DEFECTS  IN  THE  TISSUES. 

of  common  salt.  Antiseptic  sohitions  like  bichloride  of  mercury  and 
carbolic  acid  should  not  be  used,  as  they  endanger  the  vitality  of  the 
(^ells  in  the  pieces  of  skin  to  be  transplanted.  The  latter  are  taken 
preferably  from  the  arm  or  the  lower  extremity,  etc.  The  area  of  skin 
in  question  is  thoroughly  washed  with  sterilised  soap  and  warm  water 
and  shaved.  As  large  a  razor  as  possible,  or  a  microtome,  is  covered 
with  sterilised  oil,  and  while  the  skin  to  be  cut  is  put  on  the  stretch,  as 
th  in  flaps  as  possible  are  shaved  off  from  it.  To  secure  rapid  healing, 
the  pieces  of  skin  should  be  laid  upon  a  wound  from  which  the  blood 
has  been  removed  as  completely  as  possible  (Garre).  The  very  thin- 
nest piece  of  skin  thus  obtained  contains,  besides  the  entire  thickness 
of  the  papillary  layer,  a  part  of  the  underlying  stroma.  In  this  way 
pieces  of  skin  ten  to  twelve  centimetres  long  and  two  centimetres 
broad  can  be  made  to  heal  into  their  new  position.  The  larger  grafts 
are  carried  upon  an  especially  broad  spatula  and  then  spread  out  over 
tlie  defect  with  a  probe.  Great  care  should  be  taken  that  the  edges  of 
tlie  piece  of  skin  do  not  roll  up,  and  the  separate  pieces  should  be 
placed  next  one  another  with  their  edges  just  touching.  This  method 
is  particularly  valuable  for  fresh  cutaneous  defects  caused  by  opera- 
tions or  injuries,  for  burns  in  the  stage  of  granulation,  for  ulcers  of 
the  leg,  for  broad  and  deep  granulating  areas  following  operations  for 
necrosis,  etc.  After  removing  a  large,  soft  fibroma,  I  successfull}^  cov- 
ered with  epidermis  almost  the  entire  hairy  portion  of  the  scalp  in  one 
sitting  by  Thiersch's  method  of  skin-grafting ;  I  also  made  a  large  per- 
manent opening  into  tlie  left  pleural  cavity  for  empyema  and  tuber- 
culosis, and  changed  it  into  a  gutter  by  use  of  the  same  method  (see 
Special  Surgery,  §  126,  p.  400,  Fig.  296).  In  short,  the  method  is  an 
excellent  one.  Thiersch  has  also  transplanted  the  skin  of  a  negro  upon 
a  white  man  and  the  skin  of  a  white  man  upon  a  negro.  The  negro's 
skin  took  root  on  the  white  man  with  exceptional  rapidity,  but  the 
attempt  failed  in  the  majority  of  cases  in  which  skin  was  transplanted 
from  the  white  man  on  to  the  negro,  no  matter  whether  a  granulating 
or  a  fresh  wound  surface  was  used.  It  is  interesting  to  note  that  the 
portions  of  white  skin  implanted  on  the  negro  gradually  turned  black, 
and  vice  versa.  The  histological  investigations  of  Karg  showed  that 
the  pigment  does  not  originate  in  the  cells  of  the  I'ete  Malpighii,  but  is 
brought  to  them  by  the  wandering  cells  which  come  from  the  deeper- 
lying  portions  of  tissue  laden  with  pigment  and  find  lodgment  amongst 
the  cells  of  the  rete.  Consequently  the  white  skin  implanted  on  the 
negro  becomes  gradually  black,  and  the  negro's  skin  implanted  on  the 
white  man  becomes  white  from  ceasing  to  receive  deposits  of  pigment. 
The  pigment  particles  are  probably  identical  with  the  cell  granules 


M2.]  SKIN-GRAFTING  ACCORDING  TO  Rl^:VKRDIN  AND  THIERSCH.    143 

discovered  by  Altniann  and  by  him  called  bioblasts,  and  are  prol)ably 
formed  from  them  by  the  helj)  of  the  blood  in  some  unknown  way. 
According  to  Jarisch,  the  pigment  of  the  negro's  skin  lies  almost  en- 
tirely in  the  deeper  cells  of  the  rete  Malpighii  and  is  entirely,  or  almost 
entirely,  absent  from  the  more  superficial  cells. 

Dressings  after  Skin-grafting. — The  dressing  for  an  area  of  trans- 
planted skin  should  be  one  which  does  not  adhere  to  its  surface,  as 
the  pieces  of  skin  are  easily  torn  off  when  the  dressing  is  changed.  It 
is  best  to  cover  the  grafts  with  strips  of  sterilised  tin  or  gold  foil,  or 
rubber  tissue  dipped  in  sterilised  oil,  and  over  these  to  place  a  dressing 
of  sterilised  comj)resses  and  cotton,  wdiicli  is  bound  on  with  a  muslin 
and  then  a  gauze  bandage,  exerting  a  slight  amount  of  pressure.  Anti- 
septics should  be  left  out  of  the  dressings  altogether.  The  strips  of 
tin  foil,  etc.,  are  disinfected  by  a  bichloride  solution  (1  to  1,000)  and 
then  placed  in  sterilised  olive  oil  before  they  are  applied  to  the  wound. 

Excellent  results  can  be  obtained  in  this  way,  and  very  large  grafts 
will  promptly  become  attached,  provided  only  olive  oil  and  a  six- 
tenths-per-cent.  salt  solution  are  used,  and  the  irritation  of  carbolic  or 
bichloride  solutions  is  avoided.  I  have  also  entirely  given  up  covering 
the  transplanted  pieces  of  skin  with  iodoform.  The  first  dressing 
should  be  left  in  place  for  two,  three,  or  four  days,  and  then  removed 
with  great  care.  If  the  grafts  have  "  taken,"  the  area  they  cover  pre- 
sents a  mosaic  appearance  due  to  the  separate  pieces  of  skin  used  for 
the  grafts.  Later  on  the  borders  of  the  separate  pieces  of  skin  become 
less  and  less  marked,  and  occasionally  become  quite  indistinguishable. 
Until  the  grafts  have  become  completely  attached  it  is  best  to  use  the 
dressing  of  sterilised  olive  oil,  with  stri]:)s  of  tin  foil  01"  oiled  silk.  The 
epidermis  generally  comes  off,  and  is  liable  to  give  the  erroneous  impres- 
sion that  the  grafting  has  failed.  Success  is  easily  prevented  by  suppura- 
tion or  bleeding.  E.  Fischer  has  made  the  interesting  observation  that 
those  skin  grafts  become  attached  the  easiest  which  are  taken  from  and 
transplanted  upon  parts  which  have  previously  been  rendered  anaemic 
by  the  use  of  Esmarch's  rubber  bandage. 

Wdlfler's  Transplantation  of  Mucous  Membrane. — Wolfler  (see  Lan- 
genbeck's  Archiv,  I3d.  xxxvii)  has  successfully  transplanted  mucous 
membranes  taken  from  man  and  animals  upon  defects  in  various  mu- 
cous membranes.  His  method  is  to  be  greeted  as  a  new  and  valuable 
advance  in  the  treatment«of  defects  in  mucous  membrane,  such  as 
strictures  and  defects  in  the  urethra,  conjunctiva,  cheek,  etc.  Ger- 
suny,  Witzel,  and  others  have  remedied  defects  in  mucous  membranes 
by  turning  in  flaps  of  skin  possessing  a  pedicle  of  subcutaneous  tissue 
only  (see  page  140). 


14:4:     OPERATIONS   FOR   REMEDYING    DEFECTS  IN   THE   TISSUES. 

Implantation  of  Hair. — Scliwenninger  and  !Nussl>aum  liave  at- 
tempted to  implant  hair  by  strewing  it  over  a  granulating  area  where 
there  has  been  a  loss  of  skin.  If  the  root  sheath  still  remained  at- 
tached to  the  hair,  it  became  adherent  and  formed  a  centre  from  whicli 
cicatrisation  proceeded,  but  the  hair  itself  fell  out  after  a  few  days. 
Hairs  without  their  root  sheath  did  not  become  attached  at  all. 

Transplantation  of  Skin  and  Mucous  Membrane  from  Animals  {I^ab- 
hits^  Fr(j(ji<). — The  skin  and  mucous  membranes  of  animals  have  also 
been  successfully  transplanted  upon  man.  The  conjunctiva  of  a  rabbit 
has  been  successfully  grafted  in  a  defect  of  the  human  eyelid.  Bara- 
toux  and  Dubousquet-Laborderie  have  succeeded  in  implanting  the 
skins  of  frogs  upon  granulating  wounds  in  man.  The  pigment  disap- 
peared after  ten  days,  and  the  graft  took  on  more  and  more  the  appear- 
ance of  human  skin.  (For  the  minute  anatomical  changes  concerned 
in  the  attachment  of  skin  grafts,  see  ^  01,  The  Healing  of  Wounds.) 

§  43.  Plastic  Operations  on  other  Tissues  {Tendons^  Nerves^  Mus- 
cles^ Bones). — Plastic  operations  and  graftings  are  performed  not  only 
upon  the  external  cutaneous  surface  of  the  body,  but  also  upon  other 
tissues,  such  as  tendons,  muscles,  nerves,  and  bones.  AVe  shall  refei*  to 
this  in  detail  later  on.  At  present  the  following  brief  account  will 
suffice :  Defects  or  loss  of  substance  in  a  tendon  can  be  remedied  by 
cutting  flaps  with  pedicles  from  one  or  both  divided  ends  of  tlie 
tendon  and  bending  them  back  and  uniting  them  by  means  of  sutures 
of  catgut.  In  the  same  way  I  was  able  to  repair  a  defect  in  the  uhiar 
and  median  nerves  by  cutting  flaps  from  the  divided  ends  of  the 
nerves  to  which  the  flaps  remain  attached  by  a  pedicle.  These  flaps 
were  turned  down  into  the  defects  and  united  by  catgut  sutures.  The 
result  was  completely  successful.  (See  §  88,  Injuries  of  Xerves 
and  tlie  Regeneration  of  Xerves.)  Xussbaum  likewise  repaired  a 
defect  in  the  ulna  by  pieces  of  bone  covered  with  periosteum,  the 
graft,  which  had  a  pedicle,  being  taken  from  the  end  of  the  bone. 
Entirely  detached  portions  of  tissue  have  also  been  made  to  heal  into 
defects.  Philij)peaux,  Vulpian,  Gluck,  and  others  have  thus  ingrafted 
portions  of  a  nerve  taken  from  a  rabbit  into  defects  caused  by  loss  of 
substance  in  a  human  nerve  (see  §  88).  In  the  same  way  attempts 
have  been  made  to  remedy  defects  in  muscles  and  bones  by  ingrafting 
corresponding  kinds  of  tissue  taken  from  animals.  Loss  of  substance 
in  bone— for  example,  in  the  skull  or  after^otal  necrosis  of  one  of  the 
long  bones — can  be  remedied  by  implanting  small  pieces  of  cartilage 
or  bone  taken  from  young  animals  or  from  an  infant  (Macewen,  Oilier, 
etc.).  The  bone  fragments  should  be  small,  about  ten  millimetres  long 
and   four   to   five   millimetres  thick,  and,   to   obtain -the   best  results, 


§43.]  PLASTIC   OPERATIONS  ON   OTHER  TISSUES.  I45 

should  bo  taken  from  infants  or  young  animals,  and  preferably  from 
near  the  joints,  where  ossification  is  most  active — i.  e.,  from  the  nei<^h- 
bourhood  of  the  junction  of  the  epiphysis  with  the  diaphysis  in  long 
bones.  It  goes  without  saying  that  the  strictest  asepsis  and  immo- 
bilisation of  the  extremity  afterwards  are  indispensable  (see  §  lOl). 
Macewen  and  Poncet  have  remedied  defects  in  bone  resulting  from 
total  necrosis — for  instance,  of  the  humerus  and  the  tibia — by  trans- 
plantation repeated  many  times.  In  cases  of  pseudarthrosis,  Oilier 
and  others  have  successfully  implanted  large  fragments  of  bone  taken 
from  infants  or  young  animals,  Gluck  has  recommended  the  filling 
of  cavities  and  defects  with  foreign  bodies  of  the  most  varied  descrip- 
tion, which  are  left  permanently  in  place.  He  inserts,  for  example,  ivory 
cylinders  and  ivory  pegs  in  cases  wher^  there  is  a  loss  of  substance 
involving  the  entire  thickness  of  the  bone,  and  he  also  makes  use  of 
pieces  of  ivory  to  form  hinge  or  ball-and-socket  joints.  The  experi- 
ence of  others  in  Gluck's  osteoplastic  and  arthroplastic  methods  has 
not  been  published,  and  his  own  results  are  open  to  doubt.  Senn,  Le 
Dentu,  and  others  have  filled  in  defects  in  bone  by  means  of  pieces  of 
decalcified  bone.  Zahn,  Fischer,  etc.,  have  performed  very  interesting 
transplantation  experiments  with  materials  of  the  most  diverse  sorts, 
which  cannot  be  discussed  more  fully  at  present,  as  they  will  be  brought 
up  again  in  connection  with  injuries  of  the  bones  and  soft  parts  (see 
§  88  and  §  101),  It  need  only  be  said  that  living  bone  having  as  large 
a  pedicle  as  possible  for  supplying  its  nutrition  is  the  best  for  osteo- 
plastic operations  (the  so-called  homoeplasty  or  autoplasty).  If  a  piece 
of  dead  bone  (ivory)  is  ingrafted  in  the  wound  it  remains  a  dead  body, 
and  only  fills  the  space  it  occupies  for  a  certain  length  of  time  (het- 
eroplasty). 


11 


SECOND  SECTION. 
THE  METHODS  OF  APPLYING  SURGICAL  DRESSINGS. 


CHAPTER   I. 

THE   ANTISEPTIC   AND   ASEPTIC   PKOTECTIVE   DRESSINGS    FOE   WOUNDS. 

General  principles  governing  the  antiseptic  and  aseptic  dressing  of  wounds. — History. 
—The  typical  Lister  dressing;  its  simplification, — Antisepsis  and  asepsis. — The 
most  commonly  used  antiseptic  or  aseptic  dressing  materials  (gauze,  cotton,  jute, 
lint,  wood  fibre,  moss,  etc.). — The  different  antiseptics ;  their  uses  and  dangers 
(poisoning  from  carbolic  acid,  bichloride  of  mercury,  iodoform,  etc.). — Which  anti- 
septics are  of  value  ? — Which  antiseptic  and  aseptic  methods  of  dressing  are  the 
best? — Antiseptic  and  aseptic  change  of  dressings. 

§  44.  General  Principles  governing  Antiseptic  or  Aseptic  Dressings, — 

After  learning,  in  the  previous  section,  the  main  princii)les  gijverning 
the  modern  aseptic  method  of  performing  operations,  we  come  to  the 
question  of  what  dressings  should  be  nsed  for  covering  the  wound, 
and  the  discussion  of  the  methods  of  applying  surgical  dressings.  It 
is  a  part  of  surgical  teclini(pie  which  requires  indefatigable  diligence 
and  care.  A  correct  application  of  the  dressings,  and  a  carefully  con- 
ducted after-treatment  of  those  who  have  been  operated  upon  or 
wounded,  are  matters  of  the  greatest  importance. 

As  we  are  aware  that  all  infection  of  the  wonnd  is  caused  by  micro- 
organisms, by  the  omnipresent  bacteria,  it  follows  that  we  should  con- 
duct the  after-treatment  of  the  wound  in  such  a  way  as  to  preserve  it 
from  the  damaging  effects  produced  by  micro-organisms,  and  with  the 
same  care  that  is  nsed  in  performing  an  aseptic  operation. 

The  surest  and  simplest  way  of  preventing  subsequent  infection  in 
a  clean,  aseptic  wound — such  as  one  resulting  from  an  operation — is  to 
cover  it  with  a  germ-free  dressing  which  has  been  sterilised  by  hot 
steam  (see  pages  13,  14).  In  private  practice,  dressings  are  still  much 
used  which  have  been  impregnated  with  antiseptics  like  carbolic  acid 
and  bichloride  of  mercury.  That  method  of  treating  a  wound  is  the 
best  which  offers  the  greatest  security  against  subsequent  infection  and 

(146) 


§44.J   GENERAL  PRINCIPLES  GOVERNING  ANTISEPTIC  DRESSINGS.   I47 

most  readily  carries  off  and  absorbs  the  discliarge  from  tlie  wound. 
We  operate,  without  exception,  according  to  the  rules  of  asepsis,  and 
consequently  the  same  preventive  measures  should  be  carried  out  in  the 
after-treatment  of  the  wound  until  it  has  become  entirely  healed.  In- 
fected wounds  are  to  be  cleaned  as  perfectly  as  possible  from  any  dirt 
or  foreign  bodies  which  inay  be  present,  and  are  best  disinfected  by  a 
1  to  1,000  solution  of  bichloride  of  mercury. 

Historical  Remarks  on  the  Listerian  Method  of  treating  "Wounds.— The 
antiseptic  as  well  as  the  aseptic  occlusive  dressing  for  wounds  has  advanced 
very  gradually  to  its  present  state  of  perfection.  Lister  began  the  use  of  hiss 
antiseptic  occlusive  dressing  at  the  Glasgow  hospital  in  186.5,  and  published 
his  first  communication  on  the  svibject  in  1867.  Thiersch  was  the  first  Ger- 
man sm'geon  to  bring  into  notice  Lister's  antiseptic  method  of  treating  wounds, 
de.scribing  it  in  his  work  on  the  repair  of  wounds.*  Then  followed  the  con- 
tributions of  Schultz  and  Von  Lesser,  who  had  in  Edinburgh  itself  made  them- 
selves familiar  with  Lister's  methods  and  praised  them  very  highly.  Even 
before  Lister's  discovery,  antiseptics,  especially  carbolic  acid,  bad  been  used  for 
dressings,  but  to  Lister  belongs  the  immortal  honour  of  having  conceived  and 
intelligently  carried  out  the  antiseptic  method  of  operating  and  of  applying 
dressings  by  the  use  of  which  it  is  possible  to  keep  fresh  wounds  from  infec- 
tion. In  1872-'73  the  first  trials  were  made  in  Germany  with  the  Lister  dress- 
ing. In  the  German  Surgical  Congress  of  1874  Volkmann  reported  his  expe- 
riences with  the  Lister  dressing,  and  in  1875  he  published  his  "  Beitrage  zur 
Chirurgie,"  in  which  were  described  the  remarkable  and  hitherto  unheard-of 
successes  obtained  by  the  use  of  Lister's  method  of  operating  and  applying 
dressings.  In  1874-75  the  Listerian  method  came  into  general  use  in  Ger- 
many, and  then  started  on  its  triumphant  progress  over  the  entire  civilised 
world.  Never  was  surgery  so  radically  changed  for  the  better  as  after  the 
introductioH  of  Lister's  method  for  the  treatment  of  wounds.  In  the  very 
hospitals  where  the  infectious  wound  diseases  had  imaged  the  worst  during  the 
preantiseptic  period,  the  severest  operation  wounds  and  injuries  now  healed 
up  without  suppuration  and  without  secondary  disease.  After  such  remark- 
able success,  the  opponents  of  the  method  who  arose  here  and  there  were 
forced  to  give  up  the  contest. 

The  Original  Typical  Lister  Dressing. — The  typical  Lister  dressing  used 
at  first  was  applied  in  the  following  manner:  The  disinfectant  was  carbolic 
acid,  used  in  a  two-and-a-half-  to  three-per-cent.  solution  for  non-infected,  and 
in  a  four-  to  five-per-cent.  solution  for  infected  wounds.  Lister  covered  the 
wound,  or,  rather,  the  suture  line,  with  carbolic  acid  and  parafRne  spread  on 
oiled  silk,  the  whole  being  called*  a  "protective"  for  keeping  the  irritating 
substances  in  the  dressings  away  from  the  wound.  The  protective  was  made 
of  green  silk  cloth,  painted  over  with  shellac,  and  covered  on  one  side  with  a 
mixture  of  one  part  dextrin,  two  parts  pulverised  starch,  and  fifteen  parts  of 
a  five-per-cent.  cai-bolic  acid  solution.  Before  using,  the  protective  was  dis- 
infected by  a  three-per-cent.  carbolic  solution.     The  green  colour  of  the  pro- 

*  Pitha-Billroth's  Handbuch  der  Chir.,  Bd.  i,  p.  559. 


IJ^S     THE   ANTISEPTIC   AND   ASEPTIC    PPtOTECTIVE  DRESSINGS.     . 

teclive  was  changed  to  black  by  decomposition  of  the  wound-secretion,  which 
was  a  matter  of  practical  importance  for  determining  whether  the  wound  was 
perfectly  aseptic  or  not.  Besides  the  silk  protective,  a  cotton  pi'otective  was 
also  in  use.  Over  the  protectives  Lister  placed  eight  or  more  layers  of  drj- 
gauze  impregnated  with  carbolic  acid,  and  between  the  two  outermost  layers 
he  inserted  a  water-tight  material  made  of  cotton  and  gutta-percha  (mack- 
intosh). The  layei-s  of  carbolised  gauze  extended  some  distance  beyond  the 
limits  of  the  wound,  particularly  when  considerable  discharge  was  expected. 
Lister  used  carbolised  gauze  bandages  instead  of  the  ordinary  strong  muslin 
bandages.  He  impregnated  them  with  carbolic  acid  in  the  same  way  as  the 
gauze  compresses  used  in  the  dressing.  The  typical  Lister  dressing  was 
always  put  on  and  changed  in  the  early  days  under  the  carbolic  spray  (see 
page  12). 

Improvements  in  the  Original  Lister  Dressing.— Very  soon  after  its  intro- 
duction. Lister's  carbolised  gauze  dressing  was  materially  simplified  and  im- 
proved, particularly  by  German  surgeons.  The  carbolic  spraj'  used  during 
the  change  of  the  dressings  was  done  away  with,  also  the  protective  and  the 
mackintosh.  The  wound  is  now  covered  only  with  aseptic  dressings,  and 
stress  is  laid  upon  the  importance  of  having  the  secretion  from  the  wound 
dry  quickly  in  the  dressing.  The  instruments  are  sterilised  by  boiling  them 
for  five  minutes  in  a  one-per-cent.  soda  solution,  and  bichloride  of  mercury 
1  to  1.000-5.000  is  used  as  the  antiseptic  for  the  wound.  Sterilised  water,  or 
a  sterilised  six- tenth s-per  cent,  solution  of  common  salt,  is  frequently  used 
for  operations  on  such  parts  of  the  body  as  the  peritoneal  cavity,  etc.  (see  §  6). 

§  4:0.  The  Most  Common  Antiseptic  and  Aseptic  Dressings  for 
Wounds. — The  modern  surgeon  uses  particularly  : 

1.  Antisejytic  solutiotis  for  cleansing  the  wound  and  for  disinfect- 
ins:  the  materials  used  in  the  dressings.  The  most  suitable  are  three-  to 
five-per-cent.  sohitions  of  carbolic  acid,  and  aqueous  solutions  of  bi- 
chloride of  mercurv  (1  to  l,00C>-5,000).  He  also  uses  antiseptic  pow- 
ders, such  as  iodoform,  boric  acid,  salicylic  acid,  and  naphthaline,  for 
dusting  over  wounds,  especially  if  they  have  the  form  of  a  cavity  or 
are  not  closed  by  sutures,  or  are  ah'eady  suppurating  or  granulating. 

2.  Ahsorbent  matei^ls,  such  as  unstarched  gauze,  mull,  jute,  pre- 
pared moss,  wood  wool,  my  own  specially  prepared  wool,  and  cotton 
from  which  all  fatty  matter  has  been  extracted.  These  are  sterilised 
by  subjecting  them  to  steam  heat  at  a  temperature  of  100°  C.  (212°  F.) 
in  a  sterilising  apparatus. 

The  dressing  materials  impregnated  with  antiseptics,  like  carbol- 
ised and  bichloride  gauze,  were  formerly  in  very  general  use ;  but  it  is 
simpler  and  better  to  sterilise  them  all  by  heating  them  as  just  de- 
scribed, at  a  temperature  of  100°  C.  (212°  F.),  in  a  sterilising  apparatus. 
jMoreover,  it  has  been  proved  that  dressing  materials  impregnated  with 
anti.septics  and  kept  in  a  dry  condition  do  not  remain  sterile,  but  after 
a  time  all  sorts  of  bacteria  have  been  cultivated  from  them  (Schlange, 


§45.]    THE  MOST  COMMON  ANTISEPTIC  AND  ASEPTIC  DRESSINGS.    149 

Elilers,  and  others).  Bergmann,  Sclilangc,  and  Koclier  were  the  first  to 
oppose  the  use  of  these  kinds  of  dressings;  and  in  the  surgical  clinic 
of  the  Berlin  University  and  in  Copenhagen  (Bloch),  Tuaterials  for 
dressings  were  first  used  which  had  been  sterilised  sinijily  by  passing 
through  them  steam  at  a  temperature  of  100°  C.  (212°  F.). 

The  modern  surgeon  no  longer  uses  for  dressing  wounds  the  mate- 
rial called  charpie,  which  was  formerly  much  in  vogue,  and  consisted 
of  bundles  of  thread  made  by  pulling  to  pieces  bits  of  linen  cloth. 
This  charpie  has  caused  much  harm  ;  it  was  full  of  dirt  and  wound- 
poisons,  and,  consequently,  has  killed  many  a  patient  by  exciting  suppu- 
ration and  infectious  M'ound  diseases  (erysipelas,  pyaemia,  septicaemia). 

The  dressing  materials  are  fastened  in  place  by  mull  bandages 
Mdiich  have  been  soaked  hi  a  three-per-cent.  carbolic  or  1  to  1,000 
bichloride  solution,  and  gauze  bandages  are  applied  over  these.  The 
bandages  subsequently  dry  and  cause  the  whole  dressing  to  form  a 
firm,  well-fitting  support.  When  it  is  necessary  to  immobilise  an 
extremity,  the  dressing  may  be  strengthened  by  adding  splints  of 
wood,  metal,  wire,  or  thin  pliable  wooden  hoops. 

Of  the  numerous  materials  used  for  making  antiseptic  dressings, 
the  following  are  in  most  common  use  : 

Mull  or  Gauze. — The  most  extensively  employed  material  is  soft,  unfin- 
ished gauze  or  raull.  Mull  is  a  most  excellent  substance  for  dressings,  being 
soft  and  a  good  absorbent,  but  is  somewhat  expensive.  It  is  impregnated 
with  every  kind  of  antiseptic,  particularly  bichloride  of  mercury,  carbolic 
acid,  and  iodoform,  but  it  is  best  sterilised  by  subjecting  it  to  steam  heat  at 
100"  C.  (212°  F.).  as  we  have  described.  For  the  method  of  preparing  this  or 
that  particular  kind  of  antiseptic  mull — e.  g.,  carbolised,  or  bichloride,  or  iodo- 
form gauze,  etc. — reference  is  made  to  the  description  of  the  various  anti- 
septics which  is  given  further  on. 

Other  and  cheaper  materials  are  recommended  as  substitutes  for  the  more 
expensive  mull — these  are  jute,  moss,  prepared  moss,  wood  wool,  etc. 

Cotton. — Cotton  is  not  suitable  for  placing  directly  upon  the  wound,  as  it 
does  not  sufficiently  absorb  the  secretion  from  the  wound,  and  allows  it  to 
collect  underneath  and  decompose.  But  after  covering  the  wound  with  a 
good  thick  layer  of  some  absorbent  material,  like  mull  or  the  author's  pre- 
pared wool,  it  is  then  a  good  plan  to  use  dry  cotton,  which  has  been  freed 
from  fat,  as  the  outermost  covering  of  the  dressing. 

Lint. — Lint  has  been  manufactured,  especially  in  England,  since  about 
the  beginning  of  the  present  century.  In  combination  with  antiseptic  sub- 
stances, especially  boric  acid  (making  boric  lint),  it  is  very  much  used  as  an 
antiseptic  material  for  dressings. 

Jute. — Jute,  also  called  Indian  hemp,  consists  of  the  woody  fibres  of  the 
different  kinds  of  corchorus,  particularly  the  Corchorus  capsidaris,  a  plant 
growing  in  the  East  Indies  and  China.  It  is  an  excellent  substitute  for 
cotton.     Mosengeil  was  the  first  to  use  it  for  making  dressings.     It  very 


150     THE  ANTISEPTIC  AND   ASEPTIC   PROTECTIVE   DRESSINGS. 

readily  absorbs  tbe  secretions  from  tbe  wound.  Jute  is  often  impregnated 
witb  antiseptics,  sucb  as  carbolic,  salicylic  acid,  and  bichloride  of  mercury, 
and  these  forms  of  antiseptic  jute  are  prepared  practically  in  the  same  way 
as  the  corresponding  kinds  of  antiseptic  mull  or  gauze  (see  §  46).  It  is  best 
used  in  the  shape  of  jute  pads  -  that  is,  jute  sewed  up  in  bags  of  sterilised 
gauze. 

Flax,  hemp,  seaweed,  bran,  tow,  bark,  etc.,  are  used  for  dressings  in  the 
satne  way  as  jute,  and  impregnated  with  antiseptics  or  sterilised  by  subject- 
ing them  to  steam  heat  at  a  temperature  of  100°  C.  (212°  F.). 

Elax. — Flax  is  i-ecommended  by  Medwedew,  Makuschina,  and  others.  It 
is  usually  made  up  into  small  bundles,  which  are  boiled  in  lye  for  three 
hours  and  then  left  to  stand  in  the  same  liquid  for  eight  to  ten  hours  longer. 
After  washing  it  five  to  seven  times  in  clean  water,  the  flax  is  dried  and 
combed,  and  finally  becomes  a  completely  white,  soft,  and  delicate  material 
which  is  very  absorbent,  and,  like  jute,  i>;  used  in  the  form  of  small  pads. 
Flax  is  about  five  or  six  times  more  expensive  than  cotton. 

Peat. — Neuber  recommends  peat,  having,  by  chance,  observed  a  compound 
fracture  of  the  forearm  which  healed  perfectly  under  softened  peat  which 
had  been  applied  to  it.  Neuber  soaks  the  peat  in  a  1  to  1,000  solution  of 
bichloride,  and  fills  bags  of  fine-meshed  carbolised  or  bichloride  gauze  with 
it.  These  pads,  made  of  different  sizes,  are  then  used  for  dressings.  .  One 
or  more  layers  of  sterilised  gauze  are  placed  upon  the  wound  ;  then  a  small- 
sized  pad  of  peat  ;  and  next,  a  larger-sized  pad.  Peat  can  be  easily  impreg- 
nated with  antiseptics,  such  as  iodoform,  salicylic  acid,  etc.,  and  its  antiseptic 
properties  are  thus  increased.  Peat  also  readilj-  absorbs  the  secretions  from 
the  wound.  The  peat-gauze  dressing  can  be  left  in  place  several  weeks  (four 
to  six  weeks)  without  giving  rise  to  any  disturbance. 

Peat  Cotton. — Eedon  has  made  from  peat  a  material  like  cotton,  or  rather 
tow,  which  Lucas-Champouiere  considei's  suitable  as  a  dressing  for  wounds, 
on  account  of  its  softness,  its  great  power  of  absorption,  and  its  cheapness. 

Moss. — Leisrink  recommends  ordinary  moss  as  a  most  excellent  material 
for  dressings,  combining  in  itself  all  the  advantages  which  a  dressing  should 
possess.  It  is  soft,  has  gi'cat  power  of  absorption,  and  is  cheap.  Neuber's 
peat  gauze  is,  in  fact,  chiefly  made  up  of  moss.  The  dried  moss  should  be 
soaked  in  a  solution  of  bichloride  (1  to  1,000-2,000),  or  made  aseptic  by  sub- 
jecting it  to  steam  heat  at  a  temperature  of  100°  C,  and  then  used  as  a  dress- 
ing in  a  dry  state,  packed  into  sterilised  gauze  bags.  The  ^vound  is  covered 
with  two  layei-s  of  gauze  which  have  been  soaked  in  a  1  to  1,000-3,000  solu- 
tion of  bichloride,  or  else  sterilised  by  dry  heat,  and  over  these  are  laid  a 
small  and  then  a  large  moss  cushion.  Hagedorn  has  also  recommended 
moss  as  a  most  appropriate  dressing.  The  moss  should  be  collected  from 
the  woods,  picked  apai't,  dried,  and  then  heated  in  an  oven  for  several  houi-s 
at  a  temperature  of  105°-110°  C.  (221°-230°  F.).  The  dried  material  is  then 
sewed  up  in  sterilised  gauze  bags,  and  thus  used  for  dressings  in  the  form  of 
moss  cushions.  These  make  an  excellent  di'essing  for  one  which  has  to  be 
left  long  in  place.  The  different  species  of  moss  were  the  materials  used  for 
dressings  in  ancient  times. 

Moss  Felt. — Leisrink  has  recommended  tablets  of  moss  felt  in  the  place  of 
moss  cushions.     The  preparation  of  the  felt  is  as  follows  :  The  freshly  gath- 


§45.]    TUK  MOST  COMMON  ANTISEPTIC  AND  ASEPTIC  DRESSINGS.    151 

ered  moss  is  ptillod  apai-t,  washed,  and  then  steeped  in  water,  after  which  it 
is  made  int<i  felt  and  put  in  a  i)ress.  According  to  the  f^reater  or  less  amount 
of  moss  used,  thick  or  thin  tablets  are  made  which  consist  of  hard  or  soft  felt, 
depending  upon  the  pressure  exerted  upon  the  pulp.  The  dried  felt  can  be 
sewed  up  in  gauze  bags  of  different  sizes  and  shapes.  Before  using,  these 
dry  gauze-moss  tablets  are  soaked  in  a  1  to  1,000  soUition  of  bichloride,  and 
squeezed  dry  ;  or  else  they  are  sterilised  by  steam  at  a  temperature  of  100"  C, 
and  then  applied  in  the  form  of  dressings.  Leisrink  also  uses  the  thick, 
hard  tablets  as  a  splint  material  in  compound  fractures.  Hagedorn's  moss 
pulp  and  moss-gauze  pulp,  soaked  immediately  before  use  in  sterilised  salt 
solution,  water,  or  bichloride,  are  excellent  materials. 

Wood  Wool.— P.  Bruns  and  Walcher  use  for  dressings  wood  wool  or 
wood  which  has  been  rubbed  into  small  particles  by  a  grindstone.  This 
material  has  great  powers  of  absorption,  is  light,  soft,  and  cheap.  It  can  be 
impregnated  with  five  to  ten  per  cent,  of  glycerine  and  0*5  per  cent,  bichlo- 
ride, or  with  any  other  desired  antiseptic  ;  or  it  can  be  sterilised  by  steam 
at  a  temperature  of  100°  C.  The  best  wood  for  the  purpose  is  the  Pinus 
picea.  Wood  wool  is  packed  into  gauze  bags,  and  used  for  dressings  in  the 
shape  of  wood-wool  cushions.  This  dressing  is  simj^lified  by  combining 
with  the  wood  fibre  a  twenty-per-cent.  admixture  of  ordinary  cotton  wool, 
thus  rendering  the  preiiaration  of  wood-wool  cushions  superfluous.  The 
wood  wool  dressings  are  remarkable  for  their  great  absorptive  powers,  and 
they  can  be  left  in  place  upon  large  wounds  for  two  to  three  weeks,  and  the 
secretions  from  the  wound  will  become  dry  during  this  time.  Moreover,  if 
the  dressings  on  a  large  wound  become  saturated  with  the  secretions  at  the 
expiration  of  two  to  three  days,  they  need  not  be  changed,  but  simply  re-en- 
forced ty  the  addition  of  wood-wool  cushions  applied  externally.  P.  Bruns 
puts  on  the  wood-wool  dressing  in  the  following  way  :  The  wound  is  cov- 
ered first  with  a  layer  of  sterilised  spun  glass  or  gauze,  to  prevent  the  dress- 
ing from  adhering.  Over  this  is  placed  a  small  and  then  a  large  wood-wool 
or  wood-cotton  cushion,  and  the  whole  is  firmly  secured  in  place  by  a  tight 
bandage. 

Wood  Fibre.—  Kiiram el  has  recommended  wood  fibre  for  an  antiseptic 
dressing  material.  It  is  made  from  pine  or  fir  needles,  and  forms  a  dry, 
green  substance  made  up  of  fine  fibres,  and  having  a  pleasant  piny  odor. 
Wood  fibre  is  cheap,  but  does  not  absorb  so  readily  as  other  materials.  Like 
moss,  it  is  best  to  sew  it  up  in  gauze  bags,  and  after  soaking  in  sterilised 
water  and  squeezing  dry,  it  can  be  used  for  surgical  dressing. 

Sawdust. — All  other  woody  material  in  a  finely  divided  state,  like  wood 
flour  and  sawdust,  are  used  like  wood  wool.  Mikulicz  considers  sawdust, 
particularly  when  free  of  sap,  a  most  excellent  material  for  dressings,  it  being 
a  good  absorbent  and  inexpensive.  Sawdust  is  used  for  dressings  in  the  shape 
of  pads  or  cushions,  like  wood  wool  or  moss. 

Wood  Wadding. — Ronnberg  recommends  wood  wadding,  which  is  a  sub- 
stance made  during  the  process  of  manufacturing  paper.  It  is  pui*e  cellulose, 
or  a  brown,  woody  material  in  a  finely  divided  state,  which  can  be  readily 
impregnated  with  antiseptics.  Powders  like  iodoform  or  salicylic  acid,  etc., 
can  be  easily  mixed  with  it. 

Marly  Scraps. — Tolmatschew  has  recommended  marly  scraps  as  an  ex- 


152      THE   ANTISEPTIC   AND   ASEPTIC   PROTECTIVE  DRESSINGS. 

tremely  cheap  material  for  dressings.  It  is  a  product  in  the  manufacture  of 
marly  or  Scotch  gauze,  and  consists  of  thi-eady  scraps  made  in  tearing  off 
tangled  threads. 

Ash  Cushions. — Schede  and  Kiimmel  have  used  pads  made  of  ashes.  Coal 
ashes  are  freed  from  the  admixtui-e  of  coarse  particles,  and,  to  increase  their 
absorbent  power,  they  are  moistened  with  a  little  bichloride  solution  (one 
part  of  the  bichloride  solution  to  twenty-five  hundred  parts  of  the  ashes). 
They  are  then  packed  in  thin  cotton  bags  which  have  been  previously  disin- 
fected by  a  one-half-per-cent.  bichloride  solution  (with  the  addition  of  ten 
per  cent,  of  glycerine),  or  sterilized  by  heating  them  at  a  temperature  of 
100"  C.  These  soft  ash  cushions  adapt  themselves  very  well  to  the  surface  of 
the  body,  and  are  excellently  suited  for  exerting  pressure. 

Paper  "Wool. — I  can  recommend  paper  wool  as  an  excellent  absorbent  ma- 
terial, and  one  which  forms  a  soft  dressing,  very  comfortable  for  the  patient. 
It  is  made  in  the  manufacture  of  paper  from  cloth  and  is  cheaper  than  mull, 

Gedeke  uses  bichloi-ide  paper,  or  filter  paper  which  has  been  soaked  in  a 
two-tenths-per-cent.  solution  of  bichloride  (with  five  per  cent,  of  glycerine) 
and  then  dried. 

Maas  claims  that  the  absorbent  powei-s  of  dressings  can  be  increased  very 
perceptibly  by  the  addition  to  them  of  such  hygroscopic  substances  as  glyc- 
erine or  common  salt,  and  thus  those  dressings  which  have  but  little  power 
of  absorption,  such  as  cotton,  tow.  jute,  etc.,  can  be  materially  improved,  a 
consideration  which  would  be  of  much  value,  particularly  during  war  times. 

Glass  Wool. — Schede,  Kiimmel,  and  others  have  recommended  glass  wool 
as  a  substitute  for  Listers  protective.  The  very  delicate  fibres  of  spun  glass 
form  a  good  absorbent,  can  be  easily  purified  by  concentrated  acids,  and  are 
stored  in  small  bundles  in  a  one-tenth-per-cent.  solution  of  bichloride,  from 
which  they  are  taken,  and  after  gently  squeezing  them  are  laid  upon  the 
wound  in  a  tbin  layer.  This  material  keeps  the  wound,  or  the  suture  line, 
perfectly  dry  and  free  from  irritation. 

§  46.  The  Different  Antiseptics. — Of  tlie  various  aiitiseptics  wliicb 
are  employed  in  the  treatment  of  wounds  and  for  dressing  purposes, 
carbolic  acid  and  bichloride  of  mercury  are  the  most  widely  used. 
Carbolic  acid  is  the  antiseptic  which  is  most  intimately  connected  with 
the  reform  in  modern  surgery,  and  was  chosen  by  Joseph  Lister  from 
among  all  the  antiseptic  drugs  known  at  that  time  as  the  best  adapted 
for  carrying  out  his  new  methods. 

Carbolic  Acid. —  Carbolic  acid  or  phenol  (CeHeO)  was  isolated  by 
Itunge,  in  1834,  from  coal  tar.  It  forms  colourless,  hygroscopic  crys- 
tals having  a  pronounced  caustic  action,  which  are  soluble  at  ordinary 
temperatures  in  fifteen  parts  of  water,  and  are  very  poisonous  to 
plants  and  animals.  J.  K.  AVolf,  in  1840.  seems  to  have  been  the  first 
to  recognise  the  disinfecting  powers  of  carbolic  acid,  and  he  was  cer- 
tainly the  first  to  use  the  drug  for  medical  or  surgical  purposes.  In 
the  fifth  and  sixth  decades  of  this  century  carbolic  acid  was  used  in 
dressings  by  Cruveilhier,  Eigault,  Maisonneuve,  and  others,  but  to  Lis- 


§46.]  trp:  different  antiseptics.  153 

ter  belongs  tlie  lionoiir  of  bcinof  tlic  first  to   introduce  the  drug  into 
general  surgical  use. 

Preparation  of  Carbolised  Gauze. — Carbolised  gauze,  M'liich  was 
much  used  at  one  time,  is  l)est  prepared  by  Paul  Bruns's  method  :  Five 
hundred  grammes  of  soft  gauze  or  mull  are  soaked  in  a  mixture  of 
one  thou>and  parts  of  alcohol,  two  hundred  parts  of  rosin,  twenty 
parts  of  castor  oil,  and  fifty  parts  of  carbolic  acid.  At  the  present 
time  carbolic  acid,  in  .spite  of  its  poisonous  character,  is  looked  upon 
as  one  of  the  best  of  the  antiseptics,  particularly  for  the  further  disin- 
fection of  instruments  after  they  have  been  boiled  for  five  minutes  in 
a  one-per-cent.  soda  solution.  It  is  ordinarily  used  in  the  form  of  a 
two-and-a-half-  to  three-per-cent.  aqueous  solution  for  cleansing  a 
wound,  disinfecting  instruments,  for  wa-shing  out  pads  or  sponges  dur- 
ing an  operation,  for  a  spray,  or  for  the  hands.  Gartner  and  Plagge 
have  established  the  fact  that  a  three-per-cent.  aqueous  solution  of  car- 
bolic acid  will  render  micro-organisms  entirely  innocuous.  The  stronger 
five-per-cent.  solution  is  used  for  wounds  already  infected,  but  always 
with  caution  on  account  of  the  danger  of  poisoning.  The  five-per- 
cent, solution  should  invariably  be  subsequently  washed  away  by  a 
three-per-cent.  solution.  Moreover,  the  five-per-cent.  solution  is  serv- 
iceable for  disinfecting  the  field  of  operation,  and  for  storing  sponges, 
silk,  catgut,  etc.  Laplace  has  increased  the  solubility  and  the  disin- 
fecting power  of  carbolic  acid  by  the  addition  of  crude  sulphuric  acid  ; 
he  forms  a  mixture  consisting  of  twenty -five-per-cent.  crude  carbolic 
acid  with  an  equal  amount  of  crude  sulphuric  acid  of  a  similar  strength, 
and  after  heating  it  allows  the  mixture  to  cool  off.  The  same  result  is 
obtained  by  the  addition  of  a  two-per-cent.  solution  of  hydrochloric 
acid.  At  present  we  avoid  washing  out  a  wound  with  a  three-  to 
five-per-cent.  solution  of  carbolic — a  practice  which  was  formerly  much 
in  vogue — as  we  now  know  that  it  is  unnecessary  and  even  dangerous 
in  the  case  of  large  wounds.  It  should  always  be  borne  in  mind 
that  carbolic  acid  is  a  powerful  irritant  to  the  tissues,  and  is,  further- 
more, poisonous.  Children  and  antemic  and  cachectic  individuals  are 
particularly  prone  to  carbolic-acid  poisoning. 

Carbolised  Glycerine. — Carbolised  glycerine  is  an  excellent  disin- 
fectant for  instruments  and  the  hands  of  the  operator.  It  consists  of 
glycerine  containing  ten  to  twenty  per  cent,  of  carbolic  acid,  and  is 
useful  for  disinfecting  catheters,  sounds,  or  other  blunt  instruments, 
which  should  in  the  case  of  abdominal  operations  be  immersed  in  it 
for  several  hour^s.  We  smear  the  finger  with  five-per-cent.  carbolised 
glycerine  or  carbolised  vaseline  for  making  a  rectal  or  vaginal  exami- 
nation. 


154      THE   ANTISEPTIC   AND   ASEPTIC   PROTECTIVE   DRESSINGS. 

Carbolic-Acid  Poisoning. — Carbolic  acid  is,  as  has  been  said,  poisonous, 
and,  even  when  used  externally,  can  produce  dangerous  symptoms  which 
may  terminate  in  death.  I  once  saw  a  very  rapidly  fatal  case  of  poisoning 
in  a  student.  A  friend  gave  him  a  teaspoonful  of  five-per-cent.  carbolic 
acid  by  mistake,  and  unfortunately  the  stomach  pump  was  not  used  by  the 
physician  called  in.  In  another  similar  case  the  patient  was  saved  by  im- 
mediately washing  out  the  stomach. 

The  symptoms  of  carbolic-acid  poisoning  are  headache,  dizziness,  nausea, 
and  vomiting.  The  change  in  the  colour  of  the  urine  to  olive  green  or  black 
is  an  important  symptom  in  making  the  diagnosis.  But  the  intensity  of  the 
poisoning  bears  no  constant  relationship)  to  the  intensity  of  the  discolouration 
of  the  urine.  With  even  strikingly  dark  urine  the  patient  may  feel  very 
well.  The  carbolic  acid  is  found  in  the  urine  in  the  form  of  phenol-sul- 
phuric acid.  In  the  most  severe  cases  there  ensue  bloody  diarrhoea,  ha^mo- 
globinuria,  and  symptoms  of  collapse,  and  convulsions  caused  by  the  in- 
creased reflex  excitability  of  the  spinal  cord  (Salkowsky,  Gies.) ;  then  fol- 
lows a  marked  fall  of  temperature,  the  pupils  react  slowly  or  not  at  all,  the 
respiration  becomes  superficial,  consciousness  is  lost,  and  death  takes  place 
from  paralysis  of  the  vasomotor  centre  in  the  medulla.  In  the  case  of  chil- 
dren and  weakly  individuals,  the  external  application  of  carbolic  acid  should 
be  used  with  great  caution.  Fui'thermore,  many  apparently  strong  indi- 
viduals are  very  susceptible  to  this  drug.  In  1878  I  lost  a  woman  thirty- 
nine  years  old  from  carbolic-acid  i^oisoniug,  simply  as  the  result  of  chang- 
ing the  dressing  under  the  spray  ten  days  after  the  operation  (a  laparotomy 
for  fibro-myoma  of  the  uterus).  An  extensive  carbolic  erythema  over  the 
whole  body,  accompanied  by  intestinal  haemorrhage,  caused  the  death  of  this 
patient  on  the  twenty-second  day  after  the  operation.  The  post-mortem  ex- 
amination showed  perfect  union  of  the  operation  wound  and  exceedingly 
hyperaemic  intestines  filled  with  blood.  In  the  early  days  of  the  antiseptic 
treatment  of  wounds,  cases  of  carbolic-acid  poisoning  were  comparatively 
frequent. 

Billroth,  Kiister,  and  Kocher  were  the  first  to  point  out  the  dangers  in- 
volved in  its  external  use.  Clinically  two  distinct  forms  of  phenol  poison- 
ing are  recognised — acute  carbolic-acid  poisoning,  and  the  chronic,  which 
takes  the  form  of  a  marasmus  (Falkson,  Czerny,  Kiister).  The  chronic  poi- 
soning is  characterised  by  headache,  hiccough,  debility,  and  loss  of  appetite — 
symptoms  which  were  of  frequent  occurrence  among  surgeons  who  operated 
very  mvich  under  the  carbolic  spj'ay.  Falkson  assisted  at  an  operation  for 
two  and  a  half  hours  where  a  two-per-cent.  carbolic  spray  was  used,  and  in 
the  following  twenty-four  hours  he  found  2'06  grammes  of  carbolic  acid  in 
his  urine,  an  amount  fourteen  times  greater  than  the  maximum  dose  of  0"15 
gramme  allowed  by  the  Pharmacopoeia. 

Detection  of  Carbolic  Acid  in  the  Urine.— Millon's  reagent  (a  solution  of 
mercury  in  ordinary  fuming  nitric  acid)  and  bromine  water  give  a  very 
useful  reaction  with  carbolic  acid  after  the  urine  has  been  previously  acidu- 
lated with  hydrochloric  or  sulphuric  acid  and  then  distilled.  Carbolic  urine 
assumes  a  violet  colour  upon  the  addition  of  chloride  of  iron,  and  if  warmed 
with  Millon's  reagent  it  takes  on  a  purplish-red  colour,  or  with  hypochlorite 
of  sodium  a  dark-brown  colour  ;  if  treated  with  bromine  water  a  precipitate 


§46.]  THE   DTFFKREXT   ANTISEPTICS.  155 

of  tribroiuophcnol  results.  A  very  <^ood  reaction  for  phenol  is  produced  by 
a  hydrocliloric-acid  solution  (hydrochloric  acid  lifty  centimetres,  distilled 
water  fifty  centimetres,  and  calcium  chloride  0'30  gramme)  and  a  pine 
stick  (Hop])e-Seyler,  Tommasi).  Toinmasi  describes  it  as  follows  :  Equal 
quantities  of  ui-ine  and  ether  are  shaken  together,  the  supernatant  liquid  is 
then  decanted  and  the  piece  of  slick  is  soaked  in  it  until  saturated,  when  it 
is  plunged  (luickly  into  the  hydrochloric-acid  solution  and  finally  exposed  to 
the  sunlight.  The  ensuing  reaction  consists  in  a  blue  colouration  of  the 
stick;  but  if  carbolic  acid  was  not  ])resent  in  the  urine  there  will  be  no 
change  iii  colour,  or  at  the  most  a  slight  change  to  a  faint  green  colour. 
This  reaction  will  enable  the  slightest  ti'ace  of  carbolic  acid  to  be  recognised 
in  urine  or  water.  If  the  stick  is  exposed  to  the  sunlight  too  long,  the  colour 
eventually  disapi)ears. 

The  Presence  of  Carbolic  Acid  in  the  Different  Organs  after  Poisoning.— 
Hoppe-Seyler  has  measured  amounts  of  phenol  contained  in  the  separate  or- 
gans after  phenol  poisoning,  and  he  has  found  that  the  brain  and  kidneys 
hold  more  than  the  others,  consequently  investigation  should  be  first  directed 
to  these  organs  in  cases  of  suspected  carbolic-acid  poisoning. 

Treatment  of  Carbolic-Acid  Poisoning.— The  treatment  of  poisoning  from 
this  drug  consists  in  stopping  its  use  immediate]}^— for  example,  by  removing 
the  carbolic  dressing.  Sonnenburg  has  recommended  the  internal  admin- 
istration of  Glaubei*'s  salts  (sodium  sulphate)  to  hasten  its  excretion  through 
the  kidneys  in  the  form  of  the  innocuous  sulpho-carbolate  of  sodium.  The 
sulphate  of  sodium  should  be  given  in  large  doses  by  the  mouth  or  rectum, 
though  its  efficacy  is  somewhat  doubtful.  The  rest  of  the  treatment  is  symp- 
tomatic— i.  e.,  the  symptoms  are  treated  as  they  arise,  and  stimulants  and 
large  amounts  of  water  are  given  internally.  If  the  poisoning  is  produced 
by  swallowing  carbolic  acid,  the  stomach-pump  should  be  used  immediately. 

Bichloride  of  Mercury  (corrosive  sublimate,  HgCl,,  Hydrargyrum 
bichloratuin  corrosivum)  is  one  of  the  oldest  drugs,  and,  according  to 
Pearson,  was  known  to  the  Chinese,  who  have  made  it  from  cinnabar 
from  time  immemorial.  Paracelsus  M^as  the  first  to  use  it  internally, 
bat  as  an  application  to  wounds  it  was  first  recommended  by  Bergmann 
and  Scliede,  after  Billroth,  Bucliliolz,  and  R,  Koch  had  found  out  and 
made  known  its  excellent  antiseptic  properties.  R.  Koch  showed  that 
bichloride  of  mercury,  even  in  the  dilution  of  1  to  330,000,  completely 
arrested  the  growth  of  anthrax  bacilli,  and  in  a  solution  of  a  strength 
of  1  to  1,000-5,000  almost  instantly  killed  the  anthrax  spores.  As  the 
bichloride  is  the  most  poisonous  of  all  the  salts  of  mercury,  it  was  natu- 
ral that  many  surgeons  at  first  would  have  nothing  to  do  with  it  in  the 
treatment  of  wounds.  But  now  it  is  a  great  favourite  among  surgeons, 
and  is  almost  always  used  for  disinfecting  the  field  of  operation,  the 
hands,  and  the  wound,  in  aqueous  solntions  varying  from  1  to  1,000- 
5,000.  Besides  the  positive  antiseptic  power  of  bichloride  it  has  the 
advantage  of  being  much  cheaper  than  carbolic  acid.     I  use  a  one-fifth- 


156      THE   ANTISEPTIC   AND   ASEPTIC    PROTECTIVE   DRESSINGS. 

per-cent.  solution  of  bichloride  for  tlie  storage  of  silk  (after  boiling  it 
half  an  hour  in  a  one-fifth-per-cent.  bichloride  solution)  and  of  catgut 
which  has  been  sterilised  by  the  method  already  described.  Bicliloi'ide 
is  unsuitable  for  the  disinfection  of  instruments,  as  we  have  seen,  and 
for  these  I  use  a  three-per-cent.  solution  of  carbolic  acid.  Schede  and 
I  both  use  a  one-tenth-  to  a  one-twentieth-per-cent,  solution  of  bichloride 
when  we  wish  a  powerful  disinfectant,  and  a  one-fiftieth-per-cent.  solu- 
tion when  a  weak  one. 

Stability  of  Bichloride  Solutions. — If  ordinary  water,  which  has  not 
been  distilled,  is  used  for  making  bichloride  solutions,  an  insoluble 
compound  of  mercury  will  separate  after  a  time,  which,  according  to 
Fiirbringer,  is  a  trioxychloride,  or  a  dioxychloride,  or  a  tetraoxychlo- 
ride,  and  is  thrown  down  by  the  alkaline  carbonates  in  the  water.  For 
preventing  this  precipitation  of  the  bichloride  which  occurs  in  ordinary 
spring  water,  Fiirbringer  recommends  the  addition  of  acids  (salicylic, 
hydrochloric,  and  acetic  aqids,  0*5  to  1  gramme  per  litre) ;  Laplace 
recommends  tartaric  acid  (one  part  bichloride,  five  parts 'tartaric  acid); 
while  Bergmann  and  Angerer  recommend  common  salt  (one  gramme 
sodium  chloride  to  one  gramme  bichloride  of  mercury).  These  acid 
and  common-salt  solutions  of  bichloride  of  mercury  are  exceedingly 
good  on  account  of  their  great  stability,  and  are  always  to  be  pre- 
ferred to  plain  bichloride  solutions.  The  bichloride  tablets  contain- 
ing bichloride  and  ordinary  salt,  and  recommended  by  Angerer,  are 
very  useful  for  private  and  military  practice.  They  consist  of  either 
one  gramme  or  half  a  gramme  of  bichloride  of  mercury  and  chloride 
of  sodium.  Schillinger,  Fiirbringer,  and  Y.  Meyer  have  demonstrated 
that  the  stability  of  a  bichloride  solution  depends  especially  upon 
whether  the  vessel  in  which  it  is  contained  is  air-tight  or  not,  and  also 
upon  the  amount  of  exposure  to  light,  as  light  and  air  tend  to  weaken 
the  strength  of  the  solution. 

Preparation  of  Bichloride  Gauze. — Bichloride  gauze,  which  has  been 
used  much  more  in  the  past  than  it  is  now,  is  made  by  saturating  gauze 
with  a  mixture  of  ten  parts  of  bichloi'ide  of  mercurv,  five  hundred 
parts  of  glycerine,  ten  hundred  parts  of  alcohol,  and  fifteen  hundred 
parts  of  water.  This  makes  a  mixture  which  is  sufficient  to  saturate 
about  sixty  to  seventy  metres  of  gauze,  which  should  be  dipped  into  it' 
and  then  dried.  Ordinarily  gauze  containing  one  third  per  cent,  of 
bichloride  answers  sufficiently  the  purposes  of  an  antiseptic  dressing. 
Cotton,  jute,  etc.,  can  also  be  impregnated  with  bichloride  in  the  same 
way.  Instead  of  using  dressings  which  have  been  impregnated  with 
bichloride  of  mercury,  we  now  employ  materials  which  liave  been 
sterilised  by  steam  heat  at  a  temperature  of  100°  C,  because  it  has  been 


§46.]  THE   DIFFERENT  ANTISEPTICS.  157 

proved  that  dressings  impregnated  witli  antise])ties  are,  after  a  time,  no 
longer  sterile  but  euntain  bacteria  (Laplace,  Schlange,  etc.). 

Bichloride  Poisoning. — As  we  have  previously  remarked,  hichloride 
of  inercuri/  is  a  danyerous  poison^  and  must  be  used  with  very  great 
caution,  especially  in  the  case  of  children  and  sickly  individuals.  The 
symptoms  of  poisoning  manifested  after  the  external  exhibition  of  tlie 
drug  consist  in  a  feeling  of  dizziness,  restlessness,  general  malaise, 
vomiting,  salivation,  ulcerative  stomatitis  of  the  gums,  and  toward  the 
last  there  is  a  bloody  diarrhoea  and  occasionally  bleeding  from  the 
mouth  and  nose.  The  urine  contains  mercury  and  albumen.  Locally, 
when  the  bichloride  dressing  has  been  applied,  there  is  sometimes  an 
eczema,  with  persistent  itching  and  burning  of  the  skin,  particularly  if 
the  dressings  have  been  put  on  too  wet,  and  this  should  therefore  be 
avoided.  It  is  necessary,  moreover,  to  use  bichloride  of  mercury  care- 
fully in  the  interests  of  the  physician  and  of  the  assistants.  Even  then 
they  will  occasionally  show  signs  of  poisoning  in  the  form  of  saliva- 
tion and  inflammation  of  the  gums,  or  mercury  and  albumen  will  be 
present  in  the  urine.  I  have  never  yet  seen  dangerous  symptoms  of 
poisoning  occur  in  patients  whom  1  have  treated  myself,  and  only  now 
and  then  slight  stomatitis  and  eczema.  Since  asepsis  has  taken  the 
place  of  antisepsis  in  operations,  and  we  have  limited  the  use  of  bichlo- 
ride, the  cases  of  poisoning  from  this  drug,  like  those  from  carbolic 
acid,  have  become  much  less  common.  One  should  operate  as  "  dry  " 
as  possible,  and  avoid  irrigating  and  washing  out  the  wound  with  bi- 
chloride solutions  whenever  this  can  be  done,  and  use  only  dressings 
which  have  been  sterilised  by  steam,  etc.  Operations  in  the  thorax, 
peritoneal  cavity,  rectum,  and  vagina  must  be  conducted  with  very 
great  care  as  regards  the  use  of  bichloride,  and  the  latter  should  not  be 
employed  for  washing  out  the  pleural  cavity  after  an  operation  for 
empyema,  nor  for  irrigating  the  uterus  or  rectum,  etc. 

Bichloride  Poisoning  from  very  small  Amounts  of  Bichloride.— Fatal  cases 
of  bichloride  poisoning-  are  soinetimes  caused  by  very  small  amounts  of  the 
salt.  Thus  Mikulicz  lost  a  female  patient  fifty-six  years  old  who  otherwise 
"was  apparently  sound,  after  amputating  the  breast  and  clearing  the  carci- 
nomatous glands  out  of  the  axilla.  In  this  case  the  bichloride  was  only 
used  in  the  dressings,  which  consisted  of  sawdust  cushions  containing  one 
per  cent,  of  bichloride  of  mercury.  There  was  a  ^severe  dermatitis,  followed 
after  the  second  day  by  restlessness,  vomiting,  a  thin,  bloody  diarrhoea,  and 
bleeding  from  the  nose  and  mouth  accompanied  by  inflammation  of  the 
gums  (gingivitis).  No  mercury  was  detected  in  the  urine.  Stadfeldt  also 
lost  a  primipara  twenty-three  years  old,  from  washing  out  the  interior  of  the 
uterus  with  a  1  to  1,.500  solution  of  bichloride,  which  was  done  for  fever 
occiu-ring  five  days  after  confinement.     After  about  three  hundred  grammes. 


158      THE   ANTISEPTIC  AND   ASEPTIC    PROTECTIVE   DRESSINGS. 

had  been  used  the  patient  complained  of  headache  and  pain  in  the  hypog-as- 
trium.  Two  hours  afterwards  there  was  sweating,  wealcness,  and  vertigo, 
followed  a  few  hours  later  by  bloody  diarrhoea,  albumen  in  the  urine,  vomit- 
ing, ulceration  of  the  tongue,  etc.  There  was  no  aixlominal  pain.  On  the 
fourth  day  there  was  complete  anuria  and  cyanosis,  followed  on  the  fifth 
day  by  death.  The  post  mortem  showed  marked  swelling  of  the  cortex  of 
both  kidneys,  ulcerations  in  the  colon  with  a  very  hyperaemic  mucous  mem- 
brane, and  similar  lesions  in  the  small  intestine.  Microscopically  the  epi- 
thelium in  the  convoluted  tubules  of  the  kidneys  was  gi'anular  and  swollen, 
and  in  many  places  showed  marked  fatty  degeneration,  and  there  were  nu- 
merous hj'aline  casts.  Similar  lesions,  though  less  pronounced,  were  found 
in  the  straight  tubules.  The  spleen  was  small,  the  liver  normal,  and  mer- 
cury was  present  in  all  the  organs  (liver,  kidneys,  brain). 

Treatment  of  Bichloride  Poisoning. — The  treatment  of  poisoning  by 
bichluriJe  of  mercury  cunsist.s  in  immediateh' stopping  its  use;  the 
rest  is  symptomatic— i.  e.,  treatment  of  symptoms  as  they  arise. 

Salicylic  Acid.— Salicylic  acid  (CtHbOs)  exists  in  the  form  of  small  needle- 
shaped  crystals,  which  are  odourless,  and  only  slightly  soluble  in  cold  water 
(1  to  .300-400),  but  readily  soluble  in  hot  water,  alcohol,  ether,  or  glycerine. 
Salicylic  acid  is  not  volatile  like  carbolic  acid,  from  which  it  is  made  syn- 
thetically by  treating  carbolate  of  sodium  with  carbonic  acid  gas  at  a  tem- 
perature of  150°  C  By  the  absorption  of  carbonic  acid  the  basic  sodium 
salt  of  salicylic  acid  results,  and  the  former  treated  with  hydrochloric  acid 
produces  salicylic  acid. 

Kolbe  was  the  th'st  to  make  salicylic  acid  in  this  way,  and  Thiersch  then 
introduced  it  into  surgery.  Aside  from  its  internal  administration,  salicylic 
acid  is  extensively  used  in  surgery  as  a  dusting  powder  for  wounds  (Schmidt), 
in  solution  (1  to  300)  for  the  disinfection  of  wounds,  and  particularly  for  con- 
tinuous irrigation,  and  in  disinfecting  ointments  (one  i^art  acid  salicyl ,  six 
parts  cera  alba,  twelve  parts  parafRne,  twelve  parts  almond  oil).  As  salicylic 
acid  is  not  so  poisonous  as  carbolic  acid,  it  forms  an  excellent  substitute  for 
the  latter  in  cases  where  there  is  reason  to  fear  the  use  of  carbolic  or  bichlo- 
ride. Salicylic  acid  should  be  used  with  caution  as  a  dusting  powder  for 
wounds  which  are  liable  to  absorb  large  quantities  of  it.  since  fatal  poisoning 
has  thus  been  produced.  Schmidt  saw  two  cases  of  death  where  the  powder 
had  been  employed  very  freely,  and  though  death  was  not  to  be  ascribed  to 
the  efPects  of  salicylic  acid  alone,  it  nevertheless  had  certainly  contributed 
towards  the  fatal  termination. 

Boro-Salicylic  Solution. — Bose  has  made  the  very  practical  suggestion  of 
adding  borax  to  the  salic^'lic  solutions,  thus  increasing  the  solubility  of  the 
salicylic  acid  without  decreasing  the  effectiveness  of  its  action.  A  very  ex- 
cellent solution  for  the  antiseptic  irrigation  of  wounds  consists  of  one  part 
salicylic  acid,  six  parts  of  borax,  and  five  hundred  of  watei* — cotton  and  jute 
impregnated  with  three  and  ten  per  cent,  of  salicylic  acid  were  formerly 
nuich  in  vogue,  but  at  present  they  are  being  employed  less  and  less,  like 
all  other  materials  saturated  with  antiseptics  and  used  for  dressings. 

Acetate  of  Aluminium. — Acetate  of  aluminium,  like  all  the  salts  of  acetic 


§46.]  THE   DIFFERENT   ANTISEPTICS.  I59 

acid,  is  a  very  good  antiseptic  (Pinner)  ;  Burow,  senior  (1857),  was  the  first 
to  use  it  with  success.  He  prepared  the  substance  from  a  mixture  of  eig-ht 
pai'ts  acetate  of  lead,  five  parts  ahnn,  and  sixty-four  parts  water,  the  acetate 
of  lead  being  slowly  added  to  the  cold  alum  solution.  This  precipitated  sul- 
phate of  lead,  leaving  the  acetate  of  aluminium,  though  not  chemically  pure, 
in  solution.  The  solution  should  th<?n  be  filtered.  Since  his  time  acetate  of 
aluminium  has  been  used  as  an  antiseptic  with  the  best  results  by  a  great 
many  surgeons,  especially  for  continuous  iri-igation  of  wounds  and  for  .satu- 
rating wet  dressings  (H.  Maas).  For  continuous  irrigation  a  one-half-  to  one- 
per-ceiit.  aqueous  solution  is  the  best. 

Aceto-tartrate  of  Aluminium  is  an  easily  soluble  double  salt  having  a  strong 
antiseptic  action,  and  has  been  recommended  by  Schede  and  Klinnnel  as  an 
antiseptic  in  a  one-half-  to  three-per-cent.  solution  for  external  antiseptic 
applications,  and  in  a  tliree-  to  fiveper-cent.  aqueous  solution  for  the  disin- 
fection of  wounds,  especially  in  cases  where  carbolic  acid  cannot  be  used  on 
account  of  its  poisonous  properties. 

Thymol,  a  non-poisonous  substance,  is  the  active  principle  of  oil  of  thyme, 
which  is  obtained  from  various  species  of  thyme,  particularly  the  thymus 
vulgaris.  In  1719,  Neumann  isolated  from  oil  of  thyme  a  crystalline,  cam- 
phor-like body  which  he  called  thymol.  The  crystals  are  sparingly  soluble 
in  water,  but  readily  soluble  in  alcohol  and  ether.  Thymol  has  been  recom- 
mended by  Bouillon,  Paquel,  Ranke,  and  others  as  a  suitable  antiseptic  for 
applying  to  wounds. 

Thj'mol  is  used  in  an  aqueous  solution  in  the  strength  of  1  to  1,000,  con- 
taining, in  addition  to  the  water,  ten  parts  of  alcohol  and  twentj'  of  glycerine 
to  prevent  the  precipitation  of  the  thymol.  This  solution  can  be  used  for  the 
disinfection  of  instruments,  sponges,  hands,  and  particularly  of  the  wound. 
Thymol  gauze  is  prepared  by  mixing  together  sixteen  parts  of  thymol,  fifty 
parts  of  resin,  five  hundred  parts  of  wax,  and  one  thousand  of  gauze. 

Chloride  of  Zinc. —  Chloride  of  zinc  has  been  much  used  by  Campbell, 
De  Morgan,  and  Billroth,  and  lately  by  Kocher,  for  antiseptic  dressings  and 
for  disinfecting  wounds.  The  experiences  of  different  authors  with  the  drug 
vary  very  nmch.  Billroth  thinks  that  only  caustic  solutions  of  chloride  of 
zinc  are  of  antiseptic  value  ;  but  Kocher,  after  a  great  many  experiments,  has 
reached  the  conclusion  that  even  very  weak  solutions  (2  or  2^  to  1,000)  in 
dressings  are  sufficient  for  maintaining  a  wound  aseptic  ;  other  surgeons  use 
chloride  of  zinc  solutions  in  the  strength  of  1-3  to  100.  In  1879,  Bardeleben 
recommended  dressings  which  were  first  soaked  in  such  a  sokition  and  then 
dried  before  being  applied  :  thus,  jute  was  saturated  with  a  five-  and  ten-per- 
cent, solution  of  chloride  of  zinc  and  allowed  to  dry.  But  it  has  not  come 
into  anything  like  universal  use  in  the  treatment  of  wounds,  and  is  chiefly 
employed  as  a  caustic  in  about  an  eight-  to  ten-per-cent.  solution  to  cleanse 
fistulous  tracts,  foul  ulcers,  etc. 

Boric  Acid. — Boric  acid  (H3BO3)  exists  in  the  form  of  flat  crystals,  which 
are  only  slightly  soluble  in  cold  water  (1  to  30),  but  readily  soluble  in  hot 
water  and  in  alcohol.  It  is  usually  employed  in  a  two-  to  three-per-cent. 
solution,  though  for  irrigation  of  wounds  aqueous  solutions  of  a  strength  of 
5-10  to  100  may  be  employed.  Boric  acid  is  much  used  in  the  form  of  Lis- 
ter's boric  lint,  a  dressing  which  is  non-irritant  and  yet  strongly  antiseptic  ; 


160      THE  ANTISEPTIC   AND  ASEPTIC   PROTECTIVE  DRESSINGS. 

it  contains  equal  parts  by  weight  of  boric  acid  and  lint,  and  is  applied  to  the 
wound  in  a  dry  or  wet  state.  Boric  lint  is  very  simply  prepared  by  soaking 
lint  in  a  hot  concentrated  boric-acid  solution;  it  is  then  allowed  to  dry,  caus- 
ing the  boric  acid  to  adhere  firmly  to  the  lint  in  the  form  of  crystals. 

Boric  Ointment. — An  excellent  ointment  is  made  with  boric  acid  consist-- 
ing  of  three  parts  boric  acid,  five  parts  vaseline,  ten  parts  paraffine  ;  or  three 
parts  boric  acid,  four  parts  cera  alba,  and  twenty  parts  olive  oil.  A  simpler 
and  more  stable  mixture  is  one  of  twenty  parts  of  boric  acid  with  one  hun- 
dred parts  of  vaseline  or  ungt.  glycerini  (known  as  glyceritum  boroglycerini). 
As  a  general  thing  boric  acid  is  a  mild  antiseptic,  but  if  used  too  freely  it  mdy 
not  be  devoid  of  danger.  Molodenow  used  a  five-per-cent.  solution  very  freely 
for  washing  out  the  pleural  cavity  in  one  patient  and  a  lumbar  abscess  in 
another,  and  in  both  cases  uncontrollable  vomiting  resulted,  followed  by 
erythema  of  the  face,  and  death  from  cardiac  paralysis.  He  used  an  excess- 
ive amount  (15  kilogrammes)  of  a  five-per-cent.  solution,  continuing  the  irri- 
gation for  as  much  as  an  hour. 

Aseptin.— The  so-called  aseptin  used  in  Sweden  is  a  mixture  of  two  parts 
boric  acid,  one  part  alum,  and  eighteen  parts  of  water  ;  it  is  less  irritating 
than  carbolic  acid,  is  not  poisonous,  and  has  no  unpleasant  odour. 

Tetraboride  of  Sodium. — The  tetraboride  of  sodium  (Jaenicke)  is  more 
soluble  and  effective  than  boric  acid,  and  on  account  of  its  non-irritant  and 
non-poisonous  character  can  be  used  in  a  fifteen-  to  seventy-per-cent.  solution. 

Bismuth. — Bismuth  (subnitrate  of  bismuth)  is  a  white,  crystalline  powder 
of  an  acid  reaction,  which  is  only  slightly  soluble  in  water,  and  is  recom- 
mended by  Kocher  for  treating  wounds  and  for  antiseptic  di'essings.  Its 
antiseptic  properties  had  been  already  praised  by  Cloquet,  Velpeau,  etc. 
Bismuth  lessens  the  secretion  from  a  wound  very  perceptibly,  but  it  is  not 
an  innocuous  substance,  as  symptoms  of  poisoning  have  been  produced  when 
used  in  strong  mixtures  (ten  per  cent.)  or  in  large  amounts;  these  are  acute 
stomatitis  with  marked  swelling  of  the  gums,  tongue,  and  throat,  and  a  dark 
discolouration  of  the  edges  of  the  gums,  as  in  lead  poisoning,  diarrhoea, 
nephritis  accompanied  by  albuminuria,  and,  finally,  dark-coloured  urine. 
On  account  of  the  possibility  of  poisoning,  Kocher  uses  only  a  one-per-cent. 
bismuth  mixture.  When  inflammatory  processes  develop  about  a  fistulous 
tract  I  have  found  it  a  good  practice,  after  first  scraping  out  the  fistula  with 
a  sharp  spoon,  to  irrigate  it  thoroughly  with  a  five-per-cent.  bismuth  mixture. 

Iodoform. — Iodoform  (CIIIs)  is  a  bright  yellow  crystalline  powder, 
almost  insoluble  in  water,  acids,  and  alkalies,  but  readily  soluble  in 
ether,  chloroform,  alcohol,  volatile  oils,  and  fats.  About  2"5  to  3 
grammes  of  iodoform  are  soluble  in  one  hundred  grammes  of  olive 
oil.  It  was  first  introduced  in  1853,  and  since  186G  has  been  Inglily 
recommended  as  a  dressing  for  wounds,  particularly  in  syphilitic  cases ; 
but  to  Moleschott,  and  especially  to  Mosetig-Moorhof ,  belong  the  honour 
of  introducing  iodoform,  in  1880,  into  general  surgical  use,  and  thus 
enriching  our  methods  of  dressing  wounds  by  a  most  valuable  remedy. 
There  is   scarcely  a   material  which  is  so  extensively  employed  and 


g4G.]  THE   DIFFERENT  ANTISEPTICS.  101 

wliieli  orives  such  general  satisfaction  as  iodoform.  But  the  entliusiasm 
for  iodoform  waned  somewhat  wlien  cases  of  poisoning  terminating 
fatally  had  been  recorded.  I  also,  I  am  sorry  to  say,  have  had  two 
cases  of  fatal  iodoform  poisoning  following  an  extirpation  of  a  goitre 
and  removal  of  a  carcinomatous  larynx.  JMany  surgeons  then  Avent 
to  the  opposite  extreme,  and  expressed  the  hope  that  iodoform  would 
disappear  as  soon  as  possible  from  all  use  in  medicine  on  account  of 
its  very  poisonous  character.  At  present  we  always  employ  iodo- 
form with  great  care,  particularly  if  the  patient  is  aged  or  anaemic 
or  cachectic,  or  is  a  child,  or  has  a  diseased  heart  or  kidneys.  But 
even  perfectly  sound  individuals  may  have  an  idiosyncrasy  as  regards 
iodoform,  and  very  small  amounts  may  produce  symptoms  of  poi- 
soning. I  very  seldom  use  iodoform  as  a  dusting  powder  for  fresh 
wounds,  and  then  only  in  small  amounts.  It  should  be  applied  by  a 
brush  or  by  a  pulverising  apparatus,  or  blown  over  the  wound,  or 
dusted  over  it  through  a  piece  of  gauze,  so  that  the  surface  in  ques- 
tion is  only  lightly  covered  with  iodoform.  I  consider  it  unnecessary 
to  dust  iodoform  over  a  wound  which  has  been  sutured.  It  is  very 
useful  in  injuries  and  operations  affecting  the  nose,  throat,  mouth, 
vagina,  and  rectum,  for  syphilitic  and  tubercular  ulcers,  and  for  many 
cases  of  compound  fracture.  P.  Bruns  and  myself  have  obtained  ex- 
cellent results  from  the  injection  of  a  ten-per-cent.  iodoform  mixture 
in  glycerine  or  oil,  in  cases  of  bone  and  joint  tuberculosis  and  in  cold 
(tubercular)  abscesses.  The  drug  has  a  marked  antitubercular  power,  as 
proved  by  P.  Bruns,  Kauwerck,  and  B.  Tilanus.  Senger  recommends 
the  addition  of  formic  acid  to  iodoform  to  increase  the  efficacy  of  the 
latter.  The  proportions  are  as  follows  :  Iodoform  2*0,  glycerine  20'0, 
sodium  formate  0*5  to  I'o  (for  adults,  3"0).  According  to  Senger,  iodo- 
form only  derives  its  power  from  the  formic  and  hydriodic  acids  and 
other  decomposition  products  of  iodoform  set  free  by  oxidation  within 
the  body.  Iodoform  gauze  is  exceedingly  useful,  consisting  of  iodo- 
form 50,  ether  250,  alcohol  750,  and  gauze  500  parts ;  or  iodoform  50, 
resin  20,  glycerine  5,  and  alcohol  1,000  parts.  It  is  particularly  valu- 
able for  packing  cavities,  but  must  be  used  with  great  care  in  the  class 
of  individuals  mentioned  above,  as  I  have  seen  symptoms  of  poisoning 
after  the  use  of  iodoform  gauze  alone — for  example,  after  extirpation  of 
the  rectum  ;  and  particular  care  must  be  taken  not  to  exert  too  much 
pressure  in  the  bandages  applied  over  a  wound  which  has  been  packed 
M'ith  this  gauze.  Billroth's  sticky  iodoform  gauze  is  best  suited  for 
cavities  where  mucous  membrane  exists,  because  it  adheres  firmly  to 
the  surface  of  the  wound.  It  is  made  by  wringing  out  six  metres  of 
gauze  or  mull  in  a  solution  consisting  of  100  grammes  of  resin,  50 
12 


1G2      THE  ANTISEPTIC  AND  ASEPTIC   PROTECTIVE  DRESSINGS. 

grammes  of  glycerine,  and  1,200  grammes  of  alcohol  (95  per  cent.),  and 
after  the  gauze  has  dried,  230  grammes  of  iodoform  are  rubbed  into  it. 
Iodoform  Wicks. — Gersunj  uses  an  iodoform  wick  instead  of  iodo- 
form gauze,  and  prepares  it  in  the  same  way  as  the  latter,  which  has 
the  disadvantage  of  having  many  loose  threads  along  its  cut  edge, 
which  may  be  left  in  the  wound  and  retard  healing.  The  strand  of 
wick  is  also  more  easily  conducted  out  of  the  wound  through  an  open- 
ing in  the  skin.  An  attempt  may  be  made  to  conceal  the  very  sharp, 
saffron-like  odour  of  iodoform  by  the  addition  of  tincture  of  musk, 
bergamot  oil,  tonka  bean,  or  powdered  coffee.  The  coarse  crystal- 
line substance  should  always  be  employed,  and  not  the  fine  powder. 
The  iodoform  dressing  should  be  left  in  j)lace,  according  to  the  nature 
of  the  case,  from  two  to  four  to  eight  to  fourteen  days.  Though  iodo- 
form, particularly  during  the  first  years  of  its  use,  produced  not  in- 
frequently fatal  intoxications,  it  has  seldom  been  the  cause  of  any  poi- 
sonous symptoms  worth  mentioning  since  we  have  learned  the  necessity 
of  using  it  with  caution. 

Iodoform  Drainage  Tubes.— The  impregnation  of  di-ainag-e  tubes  with 
iodoform  lias  been  recommended  ;  they  are  soaked  for  about  an  hour  in  a 
concentrated  solution  of  iodoform  in  ether  and  then  allowed  to  dry.  Iodo- 
form is  much  used  in  the  form  of  iodoform  collodion  <1  to  10).  which  is  used 
in  place  of  the  ordinary  sticking  plaster.  Sticks  of  iodofomi  gelatine  are  now 
used  for  fistulas,  chronic  gonorrhoea,  and  similar  troubles.  Mosetig  recom- 
mends a  fifty-ijer-cent.  iodoform  glycerine  injection  for  goitre  and  for  soft 
hyperplastic  lyniphomata.  Iodoform  sticks  are  prepared  in  the  following 
way  :  Iodoform  ten  parts,  gum  arabic,  glycerine,  and  pure  starch  each  one 
part.  This  mass  is  then  rolled  into  slender  rods  or  sticks.  They  can  be 
more  simply  made  bj"  mixing  together  one  part  of  iodoform  and  two  parts 
of  cocoa  butter.     We  shall  return  to  this  subject  later  on  in  its  proper  place. 

Effect  of  Iodoform  upon  Bacteria.— Kronecker,  Heyn,  Rovsing.  and  others, 
showed  that  the  streptococcus  and  staphylococcus  pyogenes  aureus,  as  well 
as  other  bacteria,  may  live  a  week  in  iodofoim  powder  unharmed,  and  that 
therefore  iodoform  must  be  disinfected  before  it  is  used.  But  if  we  must 
admit  that  iodoform  has  no  direct  influence  over  the  bacteria,  we  neverthe- 
less know  that  it  renders  harmless  the  ptomaines  (toxine)  of  various  bacteria, 
or  rather  that  it  decomposes  the  ptomaines  into  harmless  compounds  (De 
Ruyter,  Behriug).  Neisser  showed  that  iodoform  is  decomposed  by  bacteria, 
and  that  it  then  has  an  antiseptic  action.  Of  these  decomposition  products 
free  iodine  and  hydriodic  acid  aj'e  the  most  important.  The  more  pronounced 
the  putrefaction  and  decomposition  in  a  wound,  the  more  pronounced  be- 
comes the  antibacterial  action  of  iodoform  (Neisser).  E.  di  Mattel  and  A. 
Scala  also  insist  that  iodoform  and  iodol  only  act  through  decomposition  and 
the  setting  free  of  nascent  iodine.  Iodoform  is.  strictly  speaking,  not  an 
antiseptic,  as  Schnirer  has  shown,  but  it  still  remains  a  valuable  drug  when 
comliined  with  some  antiseptic,  on  account  of  the  power  it  possesses  of  dimin- 


j$4G.J  TIIK    DIFFERExXT   ANTISEPTICS.  IG.'j 

ishintif  both  pain  and  the  .secretion  frotn  a  wound.  Accoitlin^  to  De  Ruyter 
the  iodofoi-ni-ether-alcohol  sohition  (1  to  2  to  8)  is  au  excellent  antiseptic. 
L'.  B.  Tilanus  has  demonstrated  that  iodoform  prevents,  or  at  least  checks, 
the  development  of  tubercle  bacilli,  and  even  has  a  tendency  to  destroy  them, 
tlioup:h  slowly  and  in  no  very  active  manner. 

Iodoform  Poisoning. — Scliede,  Konii;:;,  Czerny,  Koelier  and  others, 
have  described  tlie  isynqjtoms  of  iodoform  polaoning  as  iisiially  taking 
the  form  of  cardiac  and  cerebral  disturbances,  particularly  in  the  more 
severe  cases.  Cardiac  symptoms  are  usually  the  finst  to  make  their 
aj>pearance.  The  milder  cases  of  poisoning  are  characterized  by  a 
rapid,  irregular,  small  pulse ;  by  digestive  and  slight  nervous  disturb- 
ances, such  as  anorexia,  nausea,  and  linally  vomiting  ;  by  headache,  gen- 
eral malaise,  sleeplessness,  a  depressed  frame  of  mind,  etc.  In  the  more 
severe  cases  of  iodoform  poisoning  the  symptoms  may  correspond  to 
either  one  of  the  two  following  descriptions,  in  which  we  agree  with 
Konig : 

{a)  The  pulse  suddenly  becomes  rapid  and  small ;  there  is  sleepless- 
ness, great  restlessness,  delirium,  hallucinations,  maniacal  excitement, 
and  melancholia,  with  refu.sal  to  take  food.  These  symptoms  of  men- 
tal aberration  can  be  quickly  checked  by  removing  the  iodoform  dress- 
ing, but  they  may  be  prolonged  for  weeks  even  after  the  iodoform  has 
been  stopped.  Some  of  these  cases  terminate  fatally  from  cardiac  and 
respiratory  paralysis. 

(b)  After  a  brief  period  of  excitement  there  follows  a  general 
paralysis  of  the  central  nervous  system,  giving  the  picture  of  a  severe 
meningo-encephalitis  (loss  of  consciousness,  deep  sleep,  coma,  involun- 
tary discharge  of  urine  and  faeces,  accompanied  by  great  muscular  re- 
laxation). This  is  the  more  severe  form,  and  nearly  always  terminates 
fatally. 

Occasionally  there  is  observed  a  papular  or,  more  commonly,  an 
urticaria-like  eruption  on  the  skin.  Observations  upon  the  occur- 
rence of  fever  vary.  Scliede  has  seen  it  often,  others  (Konig,  Kocher, 
and  my.self)  have  noticed  it  less  frequently.  The  pulse  is  regularly 
greatly  accelerated.  The  length  of  time  that  may  elapse  between  the 
application  of  the  iodoform  dressing  and  the  first  .symptoms  of  poison- 
ing varies  very  much.  Sometimes  marked  symptoms  come  on  during 
the  very  day  of  the  operation  ;  in  other  cases  three  to  five  to  six  days,  or 
even  fourteen  days,  pass  before  they  make  their  appearance.  Iodoform 
poisoning  is  generally  acute,  but  sometimes  it  takes  a  chronic  or  sub- 
acute course,  and  the  symptoms  may  persist  several  weeks,  although  the 
drug  is  suspended  at  the  very  first  appearance  of  intoxication.  Miku- 
licz saw  one  case  terminate  fatally  after  the  expiration  of  twenty-nine 


164     THE  ANTISEPTIC  AND   ASEPTIC   PROTECTIVE  DRESSINGS. 

days.  Kouig's  statistics  seem  to  show  that,  of  all  the  eases  of  poison- 
ing that  he  could  collect  up  to  the  present  time,  the  greater  number 
were  in  individuals  advanced  in  years.  Of  thirteen  severe  and  fatal 
cases,  nine  were  in  people  over  fifty  years  of  age.  In  old  people  the 
strength  of  all  the  organs,  particularly  the  heart  and  kidneys,  is  im- 
paired, and  these  organs  in  consequence  succumb  more  readily  to  the 
influence  of  poisons.  According  to  Konig,  children  are  the  least  sus- 
ceptible to  this  danger. 

Explanation  of  Iodoform  Poisoning. — To  explain  iodoform  poisoning  we 
must,  of  course,  know  in  what  form  iodoform  enters  the  body  and  iu  what 
form  it  is  excreted.  At  the  point  where  it  comes  in  contact  with  the  tissixes 
iodine  is  split  off  and  is  absorbed  into  the  blood  as  an  alkaline  iodide  and  an 
albuminate  of  iodme  (Hogyes,  Zeller,  Harnackj.  The  albuminate  of  iodine 
decomposes  in  the  system,  forming  organic  substances  containing  iodine, 
which  are  excreted  in  the  urine  together  with  the  alkaline  iodides.  Ac- 
cording to  Harnack  and  Ludwig,  the  general  symptoms  of  iodine  poisoning 
are,  in  fact,  chieflj'  produced  by  the  iodine  in  the  form  of  an  albuminate  of 
ioduae,  or  by  the  organic  compounds  of  iodine.  It  is  well  known  that  the 
alkaline  iodides  can  be  introduced  into  the  system  in  very  large  amounts 
without  causing  the  general  symptoms  of  iodine  poisoning.  Zeller  claims 
that  only  a  fractional  part  of  the  iodine  is  excreted  in  the  urine  and  faeces 
while  the  rest  remains  in  the  system ;  and  thus  he  explains  how  iodoform 
poisoning  may  sometimes  first  make  its  appearance  after  the  expiration  of 
two  to  three  weeks.  If  iodine  is  already  present  in  the  system,  iodine  poison- 
ing is  the  more  liable  to  occur  when  iodoform  is  applied  externally  at  the 
same  time.  If  this  substance  is  then  employed  in  too  large  amounts,  and 
circumstances  favour  its  absorption,  and  if  there  is  diminished  excretion  of 
iodine  on  account  of  disease  of  the  kidneys  or  heart,  while  the  blood  is  both 
quahtatively  and  quantitatively  deficient,  under  such  circnmstances  poison- 
ing is  apt  to  make  its  appearance  rapidly  and  to  run  an  acute  course,  termi- 
nating in  death.  As  a  means  of  preventing  to  a  certain  degree  this  general 
poisoning  of  the  whole  system,  Harnack  takes  the  precaution  of  applying 
with  the  iodoform  some  harmless  alkali  in  the  locality  where  the  former  is 
used,  so  as  to  favour  the  formation  of  an  alkaline  iodide  from  the  free  iodine 
which  is  split  off  from  the  iodoform. 

From  the  reasons  just  given  it  is  plain  how  iodoform  poisoning  is  pro- 
duced by  dressings  which  exert  pressure,  or  by  those  which,  together  with 
the  iodoform,  are  frequently  renewed,  and  especially  by  the  use  of  large 
amounts  of  the  substance  when  the  kidneys  are  healthy,  or  small  amounts 
when  they  are  diseased.  Mosetig-Moorhof,  in  his  large  experience,  has 
never  seen  a  single  case  of  iodoform  poisoning,  attributing  it  to  the  fact 
that  he  never  uses  iodoform  except  in  small  amounts,  never  applies  dress- 
ings in  which  it  exists  so  as  to  exert  pressure,  and  changes  them  as  infre- 
quently as  possible  and  without  irrigation  of  the  surface  of  the  wound. 
He  also  considers  it  dangerous  to  use  carbolic  acid  .simultaneously  with 
iodoform  in  dressings,  because  the  carbolic  acid  may  produce  an  inflam- 
mation of  the  kidneys  amounting  to  an  actual  nephritis  (nephritis  carbolica). 


^46.]  THE    DIFFERENT   ANTISEPTICS.  165 

and  tlms  retard  tlie  excretion  by  the  urine  of  the  iodoform  which  has  been 
absorbed,  or,  in  other  words,  cause  it  to  be  i-etained  in  the  bhjod.  These 
statements  of  Mosetig-Moorhof  are  contirraed  by  the  experiments  of  Holger 
Mygind,  who  found  that  in  all  cases  in  which  iodoform  and  carbolic  acid 
were  used  toofother  the  iodine  reaction  was  given  in  tlie  urine  rather  later 
than  usual,  tlie  longest  time  necessary  for  it  to  appear  being  twenty-seven 
houi"S  after  ingesticm,  the  shortest  four  hours,  or  the  iodine  was  detected  in 
the  urine  only  after  all  traces  of  carbolic  acid  had  vanished.  Moreover, 
Holger  Mygind  claims  that  the  albuminuria  that  appears  during  the  use  of 
iodoform  is  only  produced  by  the  simultaneous  use  of  carbolic  acid.  It  is 
of  some  practical  value  to  note  that  the  excretion  of  iodine  is  continued  for 
a  considerable  length  of  time  after  the  use  of  iodoform  has  been  suspended  ; 
for  instance,  one  gramme  of  iodoform  gave  rise  to  a  reaction  for  iodine  for 
twenty-two  days,  and  fifteen  grammes  gave  the  iodine  reaction  in  the  urine 
for  thirty-eight  days,  etc.  The  size  of  the  wound  has  a  great  influence  upon 
the  rapidity  of  the  absorption  of  iodoform.  Granulating  wounds  absorb  it 
more  quickly  than  fresh  wounds,  and  wounds  in  which  fat  is  abundant  take 
it  up  very  rapidly.  According  to  Binz.  the  iodoform  is  dissolved  by  the 
small  particles  of  fat. 

As  we  have  before  remarked,  iodoform  produces  marked  cerebral  and 
cardiac  disturbances,  having  a  narcotic  effect  upon  animals  (dogs  and  cats), 
and  causing  death  by  paralysis  of  the  heart  and  respii-ation  (Binz,  Hagyer). 
Aschenbrandt  brought  about  a  fatal  pneumonia  by  causing  animals  to  inhale" 
iodoform  vapour.  The  post-mortem  examination  in  these  cases  revealed  ad- 
vanced fatty  degeneration  of  the  heart,  liver,  and  kidneys.  Post-mortem 
examinations  of  the  human  subject  dying  from  iodoform  poisoning  reveal 
a  similar  fatty  degeneration  of  these  organs,  and  in  addition  either  no  change 
in  the  brain  or  an  oedema  of  the  pia  mater. 

Treatment  of  Iodoform  Poisoning.— Besides  the  immediate  removal 
of  the  iodoform  dressing,  the  treatment  of  iodoform  poisoning  is 
purely  symptomatic.  In  the  worst  cases  no  treatment  has  proved 
of  any  avail.  Very  alarming  symptoms  are  apt  to  make  their  ap- 
pearance suddenly  without  any  prodromata.  It  is  impossible  to  state 
the  smallest  amount  of  iodoform  which  may  be  used  with  impunity,  as 
the  dosage  varies  for  each  individual  and  depends  on  all  the  circum- 
stances above  enumerated.  One  gramme  of  iodoform  has  been  known 
to  produce  a  transient  delirium  ;  and  Seeligmiiller  observed  melancholia 
with  hallucinations  thirty  days  after  the  administration  of  six  grammes 
of  iodoform ;  and  five  grammes  caused  the  death  of  one  of  his  cases,  a 
woman  thirty -six  years  of  age.  I  lost  one  case  in  which  a  goitre  was 
removed,  and  another  in  which  a  carcinomatous  larynx  was  extir- 
pated, in  each  of  which  cases  I  employed  about  five  grammes  of  the 
powdered  drug  together  with  the  iodoform  in  the  iodoform  gauze  used 
for  packing  the  wound.  In  still  another  case,  a  strong  man  fifty  years 
of  age,  I  saw  alarming  symptoms  follow  a  simple  dusting  of  the  suture 


106      THE   ANTISEPTIC   AND   ASEPTIC    PROTECTIVE    DRESSINGS. 

line  which  remained  at  the  termination  of  the  laparotomy,  with  four  to 
six  grammes  of  iodoform ;  stupor,  great  restlessness,  maniacal  excite- 
ment, rapid,  small  pulse,  etc.,  were  present,  but  after  four  weeks  com- 
plete recovery  took  place.  Of  course  the  dressings  were  removed  at 
the  very  first  appearance  of  the  symptoms.  The  poisoning  was  doubt- 
less caused  by  the  excessive  sweating  to  which  the  patient  was  subject 
during  the  hot  days  in  July.  In  general,  five  to  ten  grammes  of  iodo- 
form will  produce  no  marked  disturbances  in  patients  between  twenty 
and  forty  years  of  age  who  are  otherwise  healthy.  The  fine  powder 
seems  to  be  more  readily  absorbed  and  is  therefore  more  dangerous 
than  the  coarse  crystalline  substance  (Giiterbock),  Not  infrequently, 
however,  thirty  to  forty  to  eighty  grammes  of  iodoform,  and  even 
more,  have  been  employed.  It  is  not  to  be  wondered  at  that  fatal  poi- 
soning followed  in  some  cases  the  use  of  such  large  amounts. 

Detection  of  Iodine  in  the  Urine.^For  detecting  iodine  in  the  urine  there 
are  the  following  four  methods  : 

1.  The  fluid  to  be  tested  is  mixed  with  a  little  starch  paste,  dilute  sul- 
phuric acid,  and  a  drop  of  fuming  nitric  acid,  after  which  there  results  a 
bluish  colour,  which  may  change  into  dark  blue  according  to  the  amount  of 
iodine  present.  This  colour  disappears  on  warming  the  mixture,  and  re- 
appears when  it  has  cooled  off  again. 

2.  The  fluid  is  mixed  with  dilute  sulphuric  acid  and  a  drop  of  fuming 
nitric  acid,  and  then  shaken  with  chloroform,  in  which  the  iodine  is  soluble, 
producing  a  violet  colour.  Chloride  of  lime  can  be  used  instead  of  the  nitric 
acid,  and  bisulphide  of  carbon  instead  of  chloroform. 

3.  Upon  the  addition  of  equal  parts  of  oleum  terebinthinae  and  guaiacol 
to  an  equal  auioxmt  of  urine  there  results  a  deep-blue  colour  if  iodine  is 
present. 

4.  To  the  fluid  is  added  a  little  starch  paste,  dilute  sulphuric  acid,  fuming 
nitric  acid,  and  a  few  drops  of  bisulphide  of  carbon.  The  fluid  assumes  a 
blue  colour,  and,  if  shaken,  a  part  of  the  iodine  is  taken  up  by  the  bisulphide 
of  carbon,  producing  a  violet  colour,  and  whej-e  the  bisulphide  of  carbon 
touches  the  rest  of  the  fluid  a  dark-blue  ring  of  the  iodide  of  starch  gradually 
develops. 

According  to  Harnack,  this  last  test  is  the  most  delicate;  but  all  these  re- 
actions are  directly  dependent  upon  the  presence  of  iodine  in  the  urine  in 
the  form  of  an  alkaline  iodide  (iodide  of  sodium,  etc.).  He  claims  that 
iodine  derived  from  the  external  use  of  iodoform  occurs  in  the  urine  not  only 
as  an  alkaline  iodide,  but  also  as  a  compound  with  organic  substances,  and  in 
the  latter  state  does  not  give  the  above  reactions.  Harnack  noticed  in  two 
cases  that  the  test  for  iodine  in  the  urine  was  negative;  but  if  the  urine  was 
evaporated  and  the  residue  burned,  the  ashes  gave  a  very  plain  iodine  re- 
action.    His  method  is  as  follows  : 

The  urine  is  rendered  alkaline  by  the  addition  of  sodium  somewhat  in 
excess,  and  evaporated  in  a  platinum  crucible  in  which  the  residue  is  then 
burned  by  heating  the  crucible  red-hot.      The  carbonised  ash  is  then  re- 


^46.]  THE   DIFFERENT   ANTISEPTICS.  107 

Ijoalodly  treiitctl  with  liot  water  and  the  resulting'  extracts  arc  filtered.  To 
the  filtrate  is  tlu>n  added  a  few  drops  of  dilute  starch  paste  and  fuming 
nitric  acid,  together  with  a  few  drops  of  bisulphide  of  carbon.  When  the 
sohition  is  aciduhitod  witli  dilute  sulphuric  acid  the  presence  of  iodine  is  in- 
dicated by  a  blue  colour  ;  when  sliakeu,  the  bisuljdiide  of  carbon  lying  at  the 
bottom  takes  on  a  violet  tint,  and  just  above  it  there  forms  a  dark-blue  ring 
of  the  iodide  of  starch.  To  recognise  the  difference  between  the  intensity 
of  the  reaction  obtained  from  the  ash  and  from  the  urine,  the  former  must 
be  mixed  with  a  volume  of  water  equal  to  the  amount  of  the  original  un- 
evaporated  ui-ine,  and  then  the  reaction  is  carried  out  with  equal  quantities 
of  this  mixture  and  of  urine. 

Ciamician,  Mazzoui,  Pick  and  others  have  recommended  iodol  as  a 
substitute  for  iodoform ;  Perrier  and  Patin,  salol  made  from  carbolic 
and  salicylic  acids;  Siebel  and  A.  Petersen,  enroplien,  which  contains 
28"1  per  cent,  of  iodine;  and  Eichoff  has  recommended  aristol,  which  is 
a  compound  of  iodine  with  thymol.  Aristol  has  no  odour  and  is  non- 
poisonous,  and  is  particularly  useful  in  the  treatment  of  various  skin 
diseases.  Pallin  saw  a  case  of  iodol  poisoning  after  the  use  of  five 
grammes  of  this  substance  in  a  sequestrotomy  of  the  clavicle.  Salol 
sliould  be  given  internally  with  caution,  on  account  of  the  phenol  it 
contains ;  Hesselbach  observed  a  death  follow  the  administration  of 
eight  grammes  of  this  drug,  which  parted  with  about  3'04  grammes  of 
carbolic  acid  in  the  body. 

Dermatol  is  an  excellent  non-poisonous  substitute  for  iodoform,  and 
much  used  in  the  treatment  of  skin  diseases.  Those  of  the  newer  an- 
tiseptic powders  which  are  worthy  of  mention  are  diiodthioresorcin, 
sulphaminol,  and  sozoidol  {Hydrargyrum  sozoiodolicum,  Tromsdorff). 
Tlie  latter  non-poisonous  powder  is  used  in  the  form  of  a  one-per  cent, 
emulsion  in  glycerine,  gum  arabic,  and  water  as  an  ointment  for  treat- 
ing catarrh,  etc.  Peroni  and  Bovus  recommend  euphorin  in  the  place 
of  iodoform. 

Of  the  remaining  antiseptic  substances,  of  which  there  are  a  great 
number  of  considerable  merit,  I  shall  briefly  mention  the  following : 

Naphthalin. — Naphthalin  (CioHs)  was  isolated  from  coal  tar  by  Gardener 
in  1828.  It  forms  large,  shining,  colourless,  crystalline  plates  of  a  tarry 
odour  and  a  burning  taste.  It  is  insoluble  in  water,  readily  soluble  in  hot 
alcohol,  ether,  volatile  and  fixed  oils.     It  burns  with  a  bright,  sooty  flame. 

E.  Fischer  especially  has  recommended  it  as  an  antiseptic  for  the  treat- 
ment of  wounds.  Naphthalin  is  dusted  over  a  wound  in  the  same  way  as 
powdered  iodoform.  In  my  own  experience  I  have  found  naphthalin  a 
most  excellent  disinfectant.  A  foul  wound  will  quickly  clean  up  after 
dusting  it  with  naphthalin,  and  the  process  of  granulation  is  accelerated. 
Sometimes  its  use  is  accompanied  by  pain,  which  may  be  so  great  in  suscep- 
tible persons  that  its  further  employment  has  to  be  discontinued.     Naphtha- 


168      THE   ANTISEPTIC   AND   ASEPTIC   PROTECTIVE   DRESSINGS. 

lin  possesses  all  the  advantages  of  iodoform  without  having  any  poisonous 
action. 

Benzoic  Acid. — Benzoic  acid  crystallises  in  the  form  of  thin  plates  or 
needles,  which  are  only  slightly  soluble  in  cold  (1  to  500)  but  readily  solu- 
ble in  hot  water  (1  to  30),  and  in  alcohol,  ether,  and  concentrated  sulphuric 
acid.     Benzoic  acid  is  usually  employed  in  solution  in  the  strength  of  1  to  200. 

Sulpho-carbolate  of  Zinc. — Bottini  (Pavia;  has  recommended  sulpho-car- 
bolate  of  zinc  as  an  antiseptic.  It  forms  large,  white,  transparent,  odourless, 
rhomboidal  crystals,  which  are  readily  soluble  in  distilled  water,  alcohol,  and 
other  liquids.  Bottini  considers  the  sulpho-carbolate  of  zinc  better  than  all 
other  similar  antiseptics.  It  has  the  great  advantage  of  being  absolutely 
non-poisonous.     It  is  employed  in  two-  to  ten-per-cent.  solutions. 

Alcohol.— Dressings  of  alcohol  have  been  used  since  the  most  ancient 
times,  and  were  in  great  repute  even  in  Heister's  day.  In  France,  and  per- 
haps in  England,  this  liquid  finds  its  most  extensive  use,  but  in  Germany  it 
is  no  longer  employed.  Fifteen-  to  twenty-per-cent.  solutions  have  been 
used  for  washing  out  wounds  and  for  disinfecting  instruments,  sponges,  etc. 
According  to  Hack,  it  has  the  effect  of  rendering  granulations  which  have 
been  treated  with  it  incapable  of  absorbing  anything. 

Terebene. — Terebene  (CaoHie)  is  a  brownish,  oily  fluid  with  a  pleasant, 
aromatic  odour,  insoluble  in  alcohol,  ether,  water,  etc.,  but  soluble  in  all  pro- 
portions in  oil.  It  is  much  used,  particularly  in  England,  for  the  treatment 
of  wounds,  either  m  the  undiluted  form  for  badly  gi'anulating,  foul,  gan- 
grenous wounds,  or  diluted  with  equal  i^arts  of  oil  for  the  saturation  of 
dressings,  or  else  it  is  mixed  with  water  (30  to  500)  and  used  for  irrigation 
purposes. 

Eucalyptus. — Eucalyptus  is  a  volatile  oil  having  a  strong  antiseptic  ac- 
tion, and  is  made  from  the  leaves  of  the  myrtacese,  a  tree  growing  in  Bel- 
gium, Italy,  and  the  south  of  France  (the  Eucalyptus  globulus).  It  has  been 
recently  recommended  by  Schultz  as  an  excellent  non-poisonous  antiseptic. 
The  commercial  article  is  very  variable  iu  quality,  and  Schultz  advises  that" 
the  oil  be  treated  with  soda  until  its  acid  reaction  becomes  neutralised,  and 
then  be  exposed  in  sunlight  to  the  action  of  the  oxygen  in  the  air,  which 
causes  the  oil  to  lose  its  pungent  odour  and  become  non-irritating  when  used 
in  dressings.  The  oil  of  eucalyptus  can  be  mixed  with  alcohol  and  water, 
0'2  to  0'3  per  cent.,  and  then  used  as  a  fluid  iu  which  to  wring  oiit  com- 
presses. Lint  which  has  been  soaked  in  a  solution  of  one  part  oil  of  euca- 
lyptus and  ten  parts  olive  oil  can  be  used  for  applying  to  wounds. 

Iodine. — The  antiseptic  properties  of  iodine,  tincture  of  iodine,  the  solution 
of  iodine  iu  an  aqueous  iodide  of  potash  solution  and  of  iodine  vapour,  have 
been  proved  by  countless  experiments.  In  recent  times,  in  England  and 
x\merica,  the  solution  of  iodine — i.  e.,  iodine  two  parts,  iodide  of  potassium 
three  iiarts,  and  water  fortj^-eight  parts,  has  been  much  i;sed  for  dressings, 
lint  being  steeped  in  this  mixture.  The  combination  of  this  iodine  solution 
with  laudanum  is  also  highly  spoken  of.  For  cleansing  wounds,  Bryant 
recommends  iodine  water  (one  part  tincture  of  iodine  to  75  to  100  of  water). 

Other  Antiseptics. — There  are  still  to  be  mentioned  alum,  quinine,  chloral 
(1  to  4  per  cent,  in  water),  chloroform  water  (Salkowski),  chloride  of  lime, 
carbonate,  acetate,  and  chloride  of  lead,  acetic  acid,  permanganate  of  potas- 


55  46.]  THE   DIFFERENT   ANTISEPTICS.  109 

sium  (from  1  to  100-1,000),  caini)hor  and  tlio  spirits  of  camphor,  glycerine, 
sulphate  of  zinc,  citric  acid,  trichlorpheuol  (Diauin,  Popotf,  etc.,  one-  to  ten- 
per-cent.  solutions),  turpentine,  tar,  peroxide  of  hydrogen  (2  to  12  volume 
aqueous  solution),  sulphuric  acid  and  the  sulphates  and  suhsulphates  of  the 
alkalies,  picric  acid,  resorcin,  balsam  of  Peru,  common  salt  solutions,  carbon, 
pDwdei'ed  coffee,  naphthol  (soluble  in  the  proportions  of  1  to  5,000  parts  of 
water,  but  rendered  more  soluble  by  adding  alcohol;,  tannic  and  chromic 
acids,  bichromate  of  potassium,  aseptol  (two  to  ten  per  cent.),  and  aseptin 
acid  (a  five-  to  ten-per-cent.  solution  of  aseptin  acid),  etc. 

Of  the  numerous  other  antiseptics  recently  brought  to  notice  the  follow- 
ing may  be  spoken  of  : 

Trichloriodine. — Langenbuch  recommended  trichloi-iodine  (1  to  1,000-1,500) 
as  practically  devoid  of  danger,  and  as  a  suitable  material  for  the  disinfection 
of  the  instruments,  hands,  the  field  of  operation,  sponges,  etc.,  and  he  tested 
it  in  a  great  number  of  cases.  In  germicidal  power  it  stands  next  to  bichlo- 
ride of  mercury  (Riedel). 

Creolin.— Jeyes,  its  discoverer  (1875),  Kortiim,  Frohuer  and  others  recom- 
mend creolin  in  a  one-  to  two-percent,  solution,  which,  according  to  Henle, 
is  a  mixture  of  soap,  oil  of  creolin,  phenol,  and  pyridin  ;  it  combines  the  use- 
ful properties  of  bichloride  of  mercury  and  iodoform  without  their  poisonous 
effects.  Creolin  is  an  oily,  dark-brown  fluid,  smelling  of  tar,  and  is  made  by 
the  dry  distillation  of  coal  tar,  forming  with  water  a  milky  emulsion  which 
has  a  threefold  more  powerful  action  than  carbolic  acid,  and  is  used  in  a 
one-  to  two-per-cent.  solution.  Esmarch  has  given  fifty  grammes  of  creo- 
lin to  animals  internally  without  causing  any  bad  effects.  Behi'ing,  Baum- 
garten,  etc..  maintain  that  creolin  has  no  such  germicidal  properties  as  car- 
bolic acid  or  bichloride  of  mercuiy,  and  that  it  is  more  i)oisouous  than  has 
been  hitherto  sujjposed.  In  severe  cases  of  creolin  poisoning — for  example, 
after  the  internal  administration  of  large  amounts — there  occur  loss  of  con- 
sciousness, albumen  and  blood  and  renal  epithelium  in  the  urine,  enlarge- 
ment of  the  liver,  and  jaundice  (van  Ackeren). 

Peroxide  of  Hydrogen. — Love  recommends  peroxide  of  hydrogen  (two- 
to  three-per  cent,  solution),  but  it  is  rather  expensive,  and  on  account  of  its 
unstable  character  it  is  unsuited  for  an  antiseptic. 

Rotter's  Antiseptic  Solution.— Rotter  has  combined  a  great  number  of  an- 
tiseptics in  one  solution.  To  one  litre  of  water  are  added  bichloride  of  mer- 
cury 0-05  gramme,  sodium  chloride  0'25  gramme,  carbolic  acid  2"0  grammes, 
chloride  and  sulpho-carbolate  of  zinc,  each  S'O  grammes,  boric  acid  3"0 
grammes,  salicylic  acid  0-6  gramme,  thymol  O"!  gramme,  and  citric  acid  0.1 
gramme.  The  ingredients  of  this  solution  are  also  combined  in  tablet  form, 
and  called  "Eotteriu."  Eotter  also  left  out  of  this  solution  bichloride  of 
mercury  and  carbolic  acid,  and  considers  that  the  remaining  ingredients  have 
a  stronger  antiseptic  action  than  one-tenth-per-cent.  solution  of  bichloride 
ahme.  Von  Baeyer  has  demonstrated  that  all  these  different  antiseptics  com- 
bined in  the  one  solution  do  not  undergo  any  change. 

Aniline  Dyes. — Stilling  recommends  the  aniline  dyes  for  antiseptics  in  the 
form  of  an  aqueous  solution  of  (pyoktanin,  Merk.)  methyl  violet  (1  to  1,000), 
but  its  value  has  not  been  confirmed  by  others  (Carl,  Jaenicke,  Petersen,  etc.). 

Lysol. — Lysol  in  one  fourth-  to  two-percent,  aqueous  solution,  manufac- 


170      THE  ANTISEPTIC  AND  ASEPTIC   PROTECTIVE   DRlSSSlNGS. 

tured  by  Schiilke  &  Mayer,  in  Hamburg,  is  an  excellent  and  relatively  non- 
poisonous  antiseptic,  and  is  recommended  by  Engler,  E.  Schmidt,  Gerlach, 
etc.,  and  has  been  much  used  in  operations.  On  account  of  its  cheapness 
and  its  non-poisonous  character  lysol  is  very  well  adajited  for  disinfecting 
and  cleansing-  purposes,  instead  of  carbolic  acid. 

Salveol. — Salveol  (Hammer,  A.  Hiller),  a  cresol  compound  (neutral  aque- 
ous solution  of  creosol)  in  0'5-per-cent.  solutions,  has  a  more  jiowerful  anti- 
septic action  than  flve-per-cent.  carbolic  solutions,  and  it  is,  furthermore, 
comparatively  non-poisonous. 

Ichthyol. — Ichlhyol  is  extensively  used  in  the  treatment  of  various  skin 
diseases.  Latteux  commends  the  antiseptic  effect  of  five-  to  ten-per-cent. 
solutions  for  irrigating-  purposes. 

Alunmol. — Alumnol  (Heinz,  Liebrecht)  is  a  white  powder  which  is  highly 
recommended  for  the  treatment  of  skin  diseases  and  gonorrhoea,  and  in  one- 
half-  to  five-  to  ten-per-cent.  solutions  for  the  disinfection  of  cavities,  ab- 
scesses, infected  wounds,  ulcers,  etc. 

§  4Y.  Which  Antiseptics  and  which  Antiseptic  or  Aseptic  Dressings 

are  the  Best  ? — AVhich  antiseptic  amongst  the  great  number  whicli  are 
recommended  is  the  most  powerful  and  at  the  same  time  the  best 
adapted  to  the  treatment  of  wounds  ?  My  own  experience  places  car- 
bolic acid  and  bichloride  of  mercury  at  the  head  of  the  list  for  cer- 
tainty in  action,  and,  if  used  with  caution,  particularly  in  the  case  of 
cliildren  and  cachectic  individuals,  they  are  also  devoid  of  danger. 
If  one  uses  carbolic  and  bichloride  in  the  proper  way  he  will  see  no 
more  cases  of  poisoning  from  their  employment.  For  aseptic  opera- 
tions common  salt  solutions  or  simply  sterilised  water  may  be  used. 
Amongst  the  other  antiseptics  the  ones  whicli  I  consider  the  best  are 
boric  acid,  acetate  of  aluminium,  creolin,  lysol,  salicylic  acid,  iodo- 
form, oxide  of  zinc,  naphthalin,  chloride  of  zinc,  and  bismuth.  The 
method  of  their  application  has  been  sufficiently  described  above. 

Which  antiseptic  or  aseptic  material  is  the  best  for  dressings? 
Their  number  is  almost  without  limit,  and  the  choice,  as  we  have  re- 
marked, is  more  or  less  a  matter  of  taste.  But  the  great  principles 
involved  remain  the  same,  namely,  that  the  operation  must  be  con- 
ducted with  the  strictest  attention  to  asepsis  ;  that  the  arrest  of  the 
haemorrhage,  the  drainage,  and  the  suturing  of  the  wounds  should  all  be 
carried  out  with  the  greatest  care.  The  main  point  to  be  aimed  at  in 
the  application  of  a  dressing  is  that  the  secretion  of  the  wound  should 
be  well  provided  for ;  and  this  is  excellently  fulfilled  by  the  dry  gauze  or 
mull  dressing,  and  also  by  the  dressings  made  of  moss,  wood  wool,  jute, 
my  own  special  wool  prepared  for  dressings,  and  similar  materials.  Moss, 
wood  wool  or  excelsior,  jute,  etc.,  are  covered  with  sterilised  gauze  and 
applied  in  the  shape  of  sterilised  pads  or  cushions.  All  materials  used 
for  dressings  should  be  sterilised  by  steam  at  a  temperature  of  100°  C. 


^47.]  TUK   CHOICE   OP   AN   ANTISEPTIC.  171 

for  twenty  to  tliirty  iniiiutos  in  a  steam  sterilising  apparatus.  Dressings 
wliieli  have  been  impregnated  with  antiseptics  become  after  a  time  less 
ase})tie,  and,  furthermore,  produce  irritation  of  the  skin  and  cause  an 
eczema  (sec  pages  3,  4).  My  own  method  of  applying  a  dressing  is 
A'ery  simple,  and  is  ordinarily  done  as  follows:  The  wound,  or  the  su- 
ture line,  is  covered  with  several  layers  of  sterilised  gauze ;  over  this  is 
placed  cotton,  or  pads  or  cushions  of  jute  or  moss  which  have  been 
sterilised  by  steam  at  a  temperature  of  100°  C.  (212°  F.).  In  private 
practice  I  cover  the  wound  with  gauze  folded  into  several  layers 
which  has  been  dipi)ed  in  a  1  to  1,000  solution  of  bichloride  and 
wrung  dr\',  and  over  this  I  apply  a  layer  of  cotton  or  of  my  prepared 
wool.  The  less  the  wound  is  irritated  by  antiseptics,  or,  in  other 
words,  the  dryer  the  operation,  so  much  the  less  is  the  subsequent 
secretion  from  the  wound,  and  there  is  consequently  less  need  of  dress- 
ings having  great  absorptive  powers  like  moss  pulp,  wood  wool,  etc. ; 
gauze  covered  with  absorbent  cotton  or  jute  cushions  will  be  all  that  is 
required. 

To  favour  the  di-ying  of  the  secretion  from  the  wound  within  the 
dressings  the  gutta-percha  or  mackintosh  should  be  avoided,  except  in 
the  case  of  young  children,  when  some  water-tight  substance  should  be 
employed  to  prevent  the  dressings  from  becoming  soiled  by  urine, 
faeces,  etc.  .  All  the  dry  antiseptic  dressings  are  much  better  than  those 
of  the  wet  antiseptic,  occlusive  variety,  as  the  latter  are  apt  to  occasion 
an  eczema  frequently  lasting  a  good  while,  and  increase  the  danger  of 
poisoning,  particularly  from  carbolic  acid  and  bichloride  of  mercurj^ 
But,  as  we  shall  see,  wet  dressings  in  the  form  of  continuous  irrigation 
are  most  excellent  for  cases  of  extensive  suppuration  (see  pages  178, 
1Y9).  I  never  apply  antiseptic  dusting  powders,  like  iodoform,  bis- 
muth, salicylic  or  boric  acids,  to  a  wound  which  has  been  closed  by 
sutures.  This  powder  dressing  is  chiefly  suited  for  wounds  which 
have  not  been  closed  by  sutures  and  for  those  which  are  granulating  or 
suppurating.  For  these  I  always  employ  iodoform  when  possible,  but 
only  in  very  small  amounts.  But  at  present  I  very  seldom  use  pow- 
der dressings,  and  content  myself  with  packing  the  wound  with  iodo- 
form gauze.  Open  wounds — that  is,  those  which  have  not  been  sutured, 
like  one  resulting  from  extirpation  of  the  uterus  and  from  a  joint  re- 
section for  extensive  tubercular  inflammation,  etc. — are  best  treated 
by  packing  with  iodoform  gauze,  and  after  the  expiration  of  two  to 
four  days  the  packing  is  taken  out  and  the  aseptic  w^ound  is  closed  by 
secondary  sutures.  1  attach  great  importance  to  the  use  of  a  moderate 
amount  of  pressure  upon  the  wound,  particularly  after  the  extirpation 
of  tumours,  by  small  moss  cushions,  or  by  gauze  which  has  been  shaken 


172      'J^'HE   ANTISEPTIC   AND  ASEPTIC    PROTECTIVE   DRESSINGS. 


out  and  crumpled  up  into  pads.  Antiseptic  sponges  have  also  been 
employed  with  good  results  for  exerting  pressure  on  wounds.  For  an 
ointment  I  prefer  boric  acid  mixed  with  vaseline,  or  else  plain  vase- 
line alone.  If  it  is  necessary  to  disinfect  an  already  infected  wound,  I 
use  solutions  of  bichloride  of  mercury  (1  to  1,000-5,000). 

The  antiseptic  and  aseptic  dressings  should  be  as  large  as  conven- 
ient, though  I  do  not  consider  this  now  of  as  nmch  importance  as  I 
used  to.  For  applying  the  dressing  the  patient  should  be  placed  in 
the  most  suitable  position.  For  bandaging  the  head,  shoulder,  and 
thorax  the  patient  should  be  made  to  assume  a  sitting  posture,  while 
for  the  abdominal  region  a  cushioned  prop  (Fig.  117)  is  placed  under 
the  patient's  hips  while  the  latter  are  held  by  an  assistant.  Splints  of 
wood,  sheet  metal,  plaster  of  Paris,  or  wire,  etc.,  serve  to  immobilise 
an  extremity  (see  §  53).  For  less  serious  cases  thin,  pliable  wooden 
hoops  are  exceedingly  useful.  One  of  tiie  great  advantages  of  the 
antiseptic  and  aseptic  methods  of  treating  wounds  lies  in  the  fact  that 
tlie  dressing  requires  much  less  frequent  renewal  than  formerly,  when 
the  unsatisfactory  occlusive  dressing  was  employed. 

These  general  remarks  on  the  technique  of  antiseptic  or  aseptic  dress- 
ings will  suffice  at  present,  and  the  particular  way  of  dressing  this  or 
that  variety  of  operative  or  traumatic  wound  will  be  described  in  the 


Fio.  117. — Support  for  the  pelvis 
(Volkmann). 


Fig.  118. — Aseptic  dressing  for  tlit 
scalp. 


Fio.  119. — Aseptic  occlusive  dressing  for  the  head, 
neck  and  breast. 


Text-Book  on  Special  Surgery.  Figs.  118  and  119  illustrate  two  meth- 
ods for  applying  an  aseptic  dressing  to  the  skull  and  the  head,  neck, 
and  chest.     The  particulars  are  given  in  §  50. 


§48.]  THE  CHANGING   OF   AN   ANTISEPTIC   DRESSING.  17;^, 

§  48.  The  Changing  of  an  Antiseptic  or  an  Aseptic  Dressing. — AVhen 
sliall  an  ase})tic  dressing  be  changed  i  In  the  lirst  ])lace,  the  nature  of 
the  case  and  the  kind  of  operation  or  injury  must  be  considered. 

In  general  it  has  been  my  experience  that  a  change  of  the  dressing 
is  called  for  under  the  following  conditions : 

1.  AVhen  the  temperature  rises  above  38"5°  C.  (101-3°  F.). 

'2.  AVhen  the  dressing  becomes  soiled  from  without — for  example, 
by  urine  or  other  excretory  matter. 

3.  "When  the  patient  is  suffering  severe  pain. 

4.  AVhen  the  dressing  becomes  displaced  or  loosened,  or  when  the 
secretion  from  the  wound  saturates  the  dressing  to  such  an  extent  as 
to  be  apparent  externally. 

"Whenever  fever  occurs — and  I  make  a  regular  practice  of  con- 
sidering any  rise  of  temperature  above  38"5°  C.  (101'3°  F.)  under  this 
heading — I  change  the  dressing,  and  am  pretty  sure  to  find  that  there 
is  either  some  slight  disturbance  in  the  wound,  a  retention  of  the 
secretion,  or  a  stitch  which  is  too  tight,  etc.  As  a  general  thing,  in 
my  own  operations  I  have  very  seldom  observed  any  rise  in  tempera- 
ture above  38'4°  C.  (101°  F.).  Other  surgeons  have  noticed  a  rise 
of  temperature  of  several  degrees  during  the  healing  of  a  perfectly 
aseptic  wound.  Yolkmann  and  Genzmer,  especially,  have  made  in- 
vestigations upon  this  fever  and  have  called  it  the  ''  aseptic  wound 
fever."  I  have  very  seldom  seen  the  aseptic  wound  fever,  and  when 
a  rise  in  temperature  does  occur  while  the  healing  process  is  going  on 
it  will  usually  be  found  to  take  its  origin  from  some  perceptible  ab- 
normity in  the  wound.  Opinions  vary  as  to  the  cause  of  this  aseptic 
wound  fever.  Yolkmann  and  Genzmer  consider  it  an  aljsorption  fever 
produced  by  the  entrance  into  the  general  system  of  the  relatively 
homologous  products  of  metabolism  and  disintegration  which  are 
formed  in  every  wound.  Sonnenburg  and  Kiister  believe  that  aseptic 
wound  fever  is  caused  by  carbolic-acid  poisoning.  Both  of  these  views 
are  of  use  in  explaining  the  phenomena.  ]\ly  own  view  of  the  aseptic 
wound  fever  leads  me  to  believe  that  it  is  caused  by  the  absorption  of 
lymph  and  the  fibrin  ferment  from  the  blood  lying  in  the  wound. 
This  fibrin  ferment  is  formed  the  more  abundantly  the  more  the  wound 
has  been  irritated  by  carbolic  acid  or  other  strong  antiseptic  solutions. 
I  believe  I  am  not  mistaken  in  affirming  that  all  surgeons  who  make 
free  use  of  solutions  of  bichloride,  carbolic,  or  other  irritating  antisep- 
tics in  their  treatment  of  wounds,  will  frequently  notice  aseptic  rises 
in  temperature,  while  those  surgeons  who  are  cautious  in  their  use  of 
antiseptics,  and  prefer  asepsis  to  antisepsis,  will  only  observe  this  phe- 
nomenon in  a  few  exceptional  cases.     Many  surgeons — Xeuber,  for  in- 


174      THE   ANTISEPTIC   AND   ASEPTIC   PROTECTIVE   DRESSINGS. 

stance — have  recommended  that  the  dressing  be  allowed  to  remain  nn- 
disturbed  in  such  instances  of  aseptic  fever,  claiming  that  a  change  of 
dressing  only  creates  further  disturbance  in  the  wound  and  is  conse- 
qiently  haruiful.  I  cannot  agree  to  this  statement,  though  I  sel- 
dom have  to  do  with  fever  following  an  operation.  If  it  does  occur,  I 
always  change  the  dressing  as  a  matter  of  course,  if  the  temperature 
rises  above  38"5°  C.  (101"3  F.),  and  I  usually  find,  as  I  have  said,  some 
slight  variation  from  the  normal  in  the  healing  process.  I  prefer  to 
change  the  dressing  as  infrequently  as  possible,  and  I  am  particularly 
careful  to  avoid  irritating  the  wound  by  excessive  irrigation,  washing 
out,  etc.     It  can  only  do  harm. 

From  what  has  been  said  so  far,  we  can  readily  understand  the  im- 
portance of  ascertaining  a  patient's  temperature  in  the  morning  and 
evening,  or,  in  more  important  cases,  three  to  four  times  a  day,  or 
even  every  two  hours,  and  it  is  best  taken  in  the  rectum.  I  prefer,  if 
there  is  fever,  to  change  the  dressing  too  frequently  rather  than  allow 
one  to  remain  too  long.  If  the  discharge  should  soak  through  the 
dressings,  they  can  still  be  left  undisturbed,  if  only  the  external  layers 
remain  dry  and  no  fever  is  present. 

My  rules  for  changing  an  antiseptic  dressing  are  as  follows :  If 
the  wound  is  extensive,  and  there  is  considerable  discharge,  I  change 
the  first  dressing  after  the  expiration  of  twenty-four  to  thirty-six 
hours,  even  though  there  is  no  rise  in  temperature;  or  I  allow  the 
first  antiseptic  dressing  to  remain  undisturbed  till  the  end  of  the 
third  to  the  fourth  to  the  eighth  day,  according  to  the  nature  of  the 
case.  Drains  are  removed  at  the  end  of  the  first  twenty-four  hours,  or 
on  the  second  to  the  third  day,  the  stitches  generally  on  the  third  to  the 
fifth  day.  After  a  laparotomy  which  runs  a  normal  course  without 
reaction,  I  change  the  first  dressing  on  the  eighth  to  the  twelfth  day, 
according  to  the  size  of  the  abdominal  wound,  and  at  the  same  time  I 
remove  the  stitches,  though  if  the  wound  is  nnder  considerable  ten- 
sion a  stitch  here  and  there  is  left  in  place  for  a  little  while  longer. 

An  aseptic  dressing  should  he  changed  ooily  with  the  strictest  atten- 
tion to  the  rules  of  antisepsis,  and  everything  which  is  required  for  the 
dressing,  particularly  the  pieces  of  gauze,  the  bandages,  etc.,  is  to  be 
prepared  in  advance  in  the  proper  manner.  The  instruments,  such  as 
scissors,  probes,  forceps,  etc.,  should  be  boiled  in  a  one-per-cent.  soda 
solution  and  placed  in  a  three-per-cent.  solution  of  carbolic  acid ;  the 
sponges  or  gauze  pads  should  lie  in  a  one-tenth-per-cent.  solution  of 
bichloride.  The  hands  are  to  be  disinfected  with  the  greatest  care  (see 
page  9).  The  dressing  is  then  slit  up  with  strong  bandage  scissors 
(Fig.  120),  or  the  bandage  is   unwound,  and  after  it   has  been   thor- 


^48.]  TIIH   C'lIANGINO    OF   AN   ANTISEPTIC   DRESSING.  175 

oughly  washed,  disinfected,  and  sterilised  by  steam  at  100°  C,  it  may 
beusediigain  as  a  non-antiseptic  bandage;  but  it  is  a  better  ])lan  to 
burn  all  dressings  immediately  after 
they  have  been  taken  olf.  I  never  use 
the  spray  now. 

After  removing  the  bandages  and 
superficial  portions  of  the  dressing, 
the   hands   are   again   disinfected    bv 

,.       .  ,  .  "  Fig.  120. — Dressing  scissors. 

dipping   them   into   a   three-per-cent. 

solution  of  carbolic  or  1  to  1,0<»0  bichloride,  and  after  this  the  por- 
tion of  the  dressing  lying  in  contact  with  the  wound  is  removed  as  care- 
fully as  possible.  If  it  adheres  to  the  skin  or  to  the  wound,  it  sliould  be 
softened  by  squeezing  out  upon  it  a  few  drops  of  the  antiseptic  solution 
from  a  sponge.  The  wound  is  then  examined  by  pressing  here  and 
there  very  lightly  with  the  index  and  middle  lingers  to  ascertain 
whether  there  is  any  retention  of  the  secretion,  and  finally  the  drains, 
stitches,  etc.,  are  removed.  If  the  healing  process  is  progressing  nor- 
mally in  every  respect,  there  sliould  be  no  syringing  out  or  washing 
off  of  the  wound,  and  all  that  is  necessary  is  simply  the  application  of 
a  fresh  dressing.  The  forcing  of  antiseptic  solutions  through  the 
drainage-tubes  is  particularly  to  be  avoided,  as  it  always  does  harm,  and 
I  never  indulge  in  this  practice  except  when  suppuration  is  present, 
and  then  only  rarely.  If  the  drains  become  occluded  by  blood-clots 
and  are  to  remain  in  the  wound,  they  should  be  made  pervious  by 
passing  a  probe  through  them  ;  or,  better  still,  they  should  be  taken  out 
of  the  wound,  washed  in  a  three-per-cent.  solution  of  carbolic  or  1  to 
1,000  bichloride,  and  finally  reinserted  with  a  safety  pin  attached  to 
them  to  prevent  them  from  slipping  into  the  wound,  or  else  entirely 
new  drainage-tubes  may  be  employed.  Yery  often  a  stitch  which  is 
cutting  into  the  tissues  or  is  drawn  too  tight  must  be  removed  at  the 
end  of  twenty-four  to  thirty-six  hours.  The  presence  of  swelling  and 
redness  indicates  a  retention  of  the  secretion,  which  should  then  be  let 
out  by  one  or  more  incisions  -v^-ith  the  knife,  with  or  without  subse- 
quent drainage.  If  there  is  an  appreciable  amount  of  suppuration  it 
may  be  necessary  in  some  cases  to  change  the  dressing  every  day  for 
a  time,  or  to  substitute  for  the  antiseptic  occlusive  dressing  some  other 
simpler  kind.  Should  erysipelas  occur,  the  antiseptic  occlusive  dress- 
ing can  be  maintained. 

Even  when  the  wound  remains  uninterruptedly  aseptic,  bacteria  are 
commonly  found  in  the  antiseptic  or  aseptic  dressings.  These  bacteria 
belong  chiefly  to  the  non-pathogenic  species  of  skin  coccus,  and  do  not 
interfere  with  the  normal  process  of  healing.     If  the  staphylococcus 


176      THE  ANTISEPTIC  AND  ASEPTIC   PROTECTIVE  DRESSINGS. 

pyogenes  aureus  and  tlie  streptococcus  are  found,  there  will  probably 
be  a  disturbance  in  the  wound,  but  the  presence  of  the  staphylococcus 
pyogenes  albus  only  exceptionally  causes  an  infection  of  the  wound 
(Tavel.,  O.  Lang,  A.  Flach).  Dressings  which  have  been  allowed  to 
remain  in  place  a  long  time  will  give  otf  a  bad-odour  not  unlike  old 
cheese,  caused  ordinarily  by  the  decomposition  of  sweat  and  sebaceous 
matter.  Not  infrequently  there  will  be  found  an  eczema,  especially  if 
wet  carbolic  or  bichloride  dressings  have  been  used,  and  this  is  best 
treated  by  the  application  of  vaseHne  or  the  ungt.  lithargyr.  Hebraj,* 
and  by  dusting  it  over  with  bismuth  and  starch  (1  to  5-10),  or  oxide 
of  zinc  and  starch  (1  to  5-10),  or  by  applying  Xassar's  paste  (oxide 
of  zinc  and  powdered  starch  aa  10,  salicylic  acid  1,  vaseline  20).  Such 
eczemas  can  be  best  avoided  by  the  use  of  simple,  sterilised,  dry 
dressing  materials. 

If  the  wound  has  healed  there  is  generally  no  further  need  of  any 
dressing.  In  other  cases  it  may  be  necessary  to  cover  granulating  areas 
or  drainage-holes  with  some  ointment  like  boric-acid  ointment,  or  by 
sticking  plaster,  iodoform  collodion,  or  with  iodoform,  zinc  oxide,  or 
bismuth  powder,  or  with  a  piece  of  simple  dry  gauze  or  cotton.  I  very 
often  allow  an  aseptic  material  which  has  become  dry  to  remain  on 
the  wound  like  a  scab,  with  or  without  a  protecting  bandage.  After 
a  time  the  aseptic  scab  drops  off  and  the  wound  is  found  to  be  healed. 


*  Uns:uentum  diachylon. 


CHAPTER  II. 

OTHER    METHODS    OF    TREATING    WOUNDS. 

The  old-fashioned  protective  dressing. — Open  method  of  treating  wounds. — Healing 
beneath  a  scab. — Antiseptic  bathing. — Immersion. — The  use  of  warm  baths. — Cata- 
plasms.— Poultices. — Cold. — Ice. — Lister's  cooling  apparatus. — Adhesive  substances 
(sticking  plaster,  gauze  adhesive  plaster,  English  plaster,  collodion,  photoxylin, 
traumaticin,  gummi  lacea^). — Ointments. 

§  49.  Other  Dressings  for  Wounds. — The  old-fasliioned  protective 
dressings  of  sticking  plaster,  cliarpie,  ointments,  etc.,  are  no  longer 
used  at  the  present  day,  and  after  operations  we  now  cover  the  wound, 
without  exception,  with  antiseptic  or  aseptic  dressings,  though  in  the 
case  of  small  fresh  wounds,  or  those  which  are  granulating,  we  occa- 
sionally employ  adhesive  plaster,  collodion,  iodoform  collodion,  and  an- 
tiseptic salves,  boric-acid  ointment,  for  example. 

Open  Method  of  treating  Wounds. — The  open  method  of  treating 
wounds  is  the  simplest  one  of  all.  Small  superiicial  wounds  are  now 
allowed  to  go  without  any  dressing,  especially  when  the  blood  and 
secretion  from  the  wound  becomes  dried  and  thus  forms  a  protecting 
crust  beneath  which  the  M^ound  heals. 

Healing  beneath  a  Scab. — The  healing  under  a  scab,  which  occurs 
in  small  wounds,  has  been  made  the  basis  of  a  separate  method  of  treat- 
ment, in  which  an  attempt  is  made  to  form  a  scab  artificially  over 
wounds  having  an  abundant  secretion  by  the  application  of  dry  sub- 
stances, such  as  tinder  and  various  kinds  of  powders,  or  a  dry  eschar  is 
made  by  some  strong  caustic,  like  nitrate  of  silver,  liq.  ferri  sesquichlor., 
the  hot  iron,  etc.  All  these  different  ways  of  accomplishing  the  same 
result,  if  carried  out  with  no  antiseptic  precautions,  even  though  the 
wound  be  small,  are  not  devoid  of  danger.  But  the  modern  surgeon 
never  fails  to  treat  every  wound,  including  the  very  smallest,  upon  anti- 
septic principles,  because  we  know  that  even  the  most  insignificant  lesion 
in  the  skin,  under  certain  conditions,  may  cause  a  septic  cellulitis  or  an 
erysipelas  which  can  prove  fatal.  On  the  other  hand,  Schede's  method 
of  treating  wounds  by  permitting  a  moist  aseptic  blood-clot  to  remain 
(see  page  102)  is  to  be  looked  upon  as  a  real  advance  in  this  branch  of 

13  (177) 


178  OTHER  METHODS   OF   TREATING   WOUNDS. 

surgery.  As  above  stated,  it  is  an  excellent  plan  to  permit  the  dried 
dressings  to  remain  upon  the  wound  like  a  dry  aseptic  seal),  until  they 
come  away  of  their  own  accord  when  the  wound  has  healed. 

This  open  method  of  treating  wounds  yielded  relatively  excellent  results 
in  the  preantiseptic  days  of  surgery,  even  when  used  for  large  wounds,  such 
as  amputations,  disarticulations,  compound  fractures,  etc.,  and  was  practised 
till  supplanted  by  the  antiseptic  dressing. 

In  the  open  method  of  treatment  the  wound  was  not  provided  with  any 
dressing,  but  left  enth-ely  exposed,  or  only  lightly  covered  with  antiseptic 
compresses.  It  was  not  closed  with  sutures  until  later  on,  when  a  few  coap- 
tation sutures  were  used.  In  this  way  the  escape  of  the  secretion  from  the 
wound  was  favoured.  If  the  wound  was  situated  on  an  extremity  the  latter 
was  placed  in  a  proper  position  to  facilitate  the  escape  of  tbe  discharges, 
which  were  received  in  a  vessel  or  bowl  placed  beneatb.  The  crusts  which 
formed  in  the  wound,  from  dried  blood  or  secretions,  were  softened  and  re- 
moved by  means  of  antiseptic  solutions  or  by  carbolised  oil.  The  principal 
advantages  in  the  treatment  of  a  wound  by  the  open  method  were  a  ready 
escape  of  the  secretions,  complete  rest  which  was  undisturbed  by  change  of 
dressings,  and  finally  absence  of  pressure.  It  had  tbe  disadvantage  that 
wounds  healed  slowly  and  only  after  suppuration. 

In  cases  where  the  antiseptic  occlusive  dressing  is  no  longer  advis- 
able on  account  of  suppuration,  or  a  threatening  systemic  infection, 
when  it  may  even  become  dangerous  from  the  pressure  it  exerts,  the 
open  method  of  treating  wounds,  particularly  in  conjunction  with  con- 
tinuous antiseptic  irrigation,  is  now  in  very  general  use,  and  is  an 
exceedingly  valuable  means  of  handling  these  cases. 

Antiseptic  Bathing. — For  continuous  antiseptic  bathing  of  a  wound, 
or,  in  other  words,  for  continuous  irrigation,  such  antiseptic  solutions 
should  be  used  as  involve  no  danger  to  the  patient  from  their  absorp- 
tion and  produce  no  symptoms  of  poisoning.  Of  these,  the  best  are 
three-tenths-per-cent.  solutions  of  salicylic  acid  ;  the  boro-salicylic  solu- 
tion (1  part  of  salicylic  acid,  6  of  borax,  and  500  of  water) ;  or 
solutions  of  one  tenth  per  cent,  thymol,  four  per  cent,  boric  acid,  two 
per  cent,  acetate  of  aluminium,  or,  what  is  the  best  solution  of  all, 
viz.,  Burow's  (described  on  page  159),  consisting  of  ten  per  cent,  sub- 
sulphate  of  sodium,  one  tenth  per  cent,  permanganate  of  potassium,  lysol, 
etc.  The  wound  is  covered  with  a  light  gauze  compress.  The  patient 
is  made  to  assume  a  suitable  position,  and  protected  by  means  of  water- 
tight coverings  and  also  by  properly  regulating  the  overflow  of  the 
irrigation  fluid.  The  solution  is  made  to  drip  from  an  Esmarch  irri- 
gator placed  in  some  elevated  spot,  or  from  an  improvised  irrigator, 
such  as  an  inverted  champagne  bottle  from  which  the  bottom  has  been 
partly  removed  (Fig,  123),  or  the  excellent  apparatus  of  Starcke  may 


§49.1 


OTHER  DRESSINGS  FOR  WOUNDS. 


179 


be  used  (Fi"^.  122).  Fig.  121  illustrates  the  proper  position  for  the 
upper  extremity  when  continuous  antiseptic  irrigation  is  em2:)loyed. 
Starcke's  apparatus  consists  of  a  vessel  for  liolding  tluid 
which  is  connected  by  a  rubber  tube  with  a  lead  or  glass 
pipe;  this  is  litted  with  numerous  outlets  also  connected 
with  ruliber  tubes  which  can  be  opened  or  closed  by  stop- 
cocks or  clamps,  and  by  means  of  Avires  in  their  interior  can 
be  bent  and  turned  in  any  desired  direction.  The  lead  or 
glass  pipe  is  sus- 
pended from  some  It  ifj 
beam  or  support  by 
a  couple  of  strings. 

If  Esmarch's  irri- 
gator or  the  inverted 
champagne  bottle  are 
used  as  in  Fig.  123, 
the  fluid  is  made  to 
escape  in  drops  or  in 
any  required  amount 
by  means  of  a  stop- 
cock placed  at  the 
point  of  insertion  of 
the  rubber  tube.  If 
the  tube  is  not  fitted 
with  one,  the  out- 
flow of  fluid  can  be 
regulated  by  a  clamp, 
or  a  piece  of  cotton,  or  a  few  strands  of  jute  stuffed  into  the  lumen  of 
the  tube,  or  by  a  straw,  etc. 

Immersion. — Immersion,  or  bathing  the  whole  body,  or  separate 
portions  of  it  which  have  sustained  an  inju- 
ry, were  endorsed  principally  by  Langenbeck 
as  a  method  of  treating  wounds.  The  con- 
tinuous immersion  of  a  patient  s  whole  body 
in  a  warm  bath  day  and  night  is  adapted 
especially  for  extensive  burns,  cellulitis, 
bedsores,  and  for  the  after-treatment  of  op- 
erations on  the  rectum,  bladder,  urethra, 
etc.  The  bath  tub  is  usually  made  to  con- 
tain a  framework  of  wood  or  metal  fitted 
with  slats  and  a  movable  head-piece  which  can  be  raised  or  lowered. 
Covers  are  laid  over  the  frame   and   an   air   cushion   on   the   head- 


FiG.  121. — Position  of  the  upper  extremity  during  pennaneiit 
antiseptic  irrigation. 


Fig.  122. — Starcke's  apparatus  for 
the  irriiration  of  a  wound. 


180 


OTHER  METHODS  OF  TREATING  WOUNDS. 


piece,  and  thus  tlie  patient  is  made  very  comfortable.  The  patient 
can  be  placed  on  an  ordinary  sheet  instead  of  a  frame,  and  in  this 
way  can  be  raised  or  lowered  in  the  tub.  The  tem- 
perature of  the  water  must  not  be  allowed  to  become 
too  cool,  and  it  is  best  to  regulate  it  according  to  the 
wishes  of  the  patient,  and  therefore  it  is  a  good  plan 
for  him  to  be  able  to  regulate  the  temperature  of 
the  bath  himself  by  turning  on  or  letting  out  the 
water.  The  temperature  of  the  water  must  usually 
be  maintained  at  3T°  to  38°  C.  (98-6°  to  100-4°  F.), 
and  perhaps  more,  and  of  course  the  patient,  while 
asleep,  should  be  watched  very  carefully  by  a  nurse. 
Influence  of  a  Continuous  Bath  on  a  Wound. — The 
influence  of  prolonged  baths  of  this  kind  upon  a 
wound  is  in  general  very  favourable.  The  granula- 
tions usually  swell  considerably,  and  it  occasionally 
happens  for  this  reason  that  the  escape  of  the  dis- 
charges is  rendered  difficult,  causing  retention  and 
burrowing  of  pus  and  phlegmonous  inflammations. 
Nevertheless,  the  freely  granulating  surface  is  apt  to 
become  covered  with  skin  very  rapidly,  and  the  parts 
surrounding  the  wound  become  soft  and  yielding. 
For  regulating  the  growth  of  the  granulations,  irritant  substances,  like 
spirits  of  camphor,  etc.,  have  been  added  to  the  bath,  or  the  wounds 
have  Vjeen  dressed  with  them.  If  the  bath  becomes  too  cold  there  is  a 
possibility  of  necrosis  taking  place  here  and  there  in  the  skin  ;  and  care 
should  be  taken  in  subjecting  old  people  to  prolonged  baths  on  account 
of  the  danger  of  pulmonary,  cardiac,  or  cerebral  disturbances. 

The  use  of  baths  for  separate  portions  of  the  body  which  have  been 
injured  needs  no  further  description. 

The  Use  of  Continuous  Baths  for  Operative  Cases  and  Long-Continued 
Suppuration.— At  the  present  time,  Sonuenbui-g  is  a  prominent  advocate  of 
permanent  baths  for  operative  cases  and  for  all  patients  who  are  afflicted 
with  long-continued  suppuration,  and  upon  whom  the  ordinary  form  of  anti- 
septic applications  cannot  be  used,  either  on  account  of  the  peculiarities  of 
the  wound  or  other  local  conditions,  or  on  account  of  some  idiosyncrasy  of 
the  patient.  Sonnenburg  has  practised  this  method  in  operations  in  the 
pelvic  region,  in  lithotomies,  extirpation  of  the  rectum  and  uterus,  urethrot- 
omy, intestinal  operations,  for  bedsores,  burns,  extensive  cellulitis,  etc.  Many 
patients  can  be  kept  for  months  in  a  bath  at  a  temperature  of  about  30°  C. 
(995°  F.).  The  wound  drains  readily,  and  accidental  wound  diseases  do  not 
occur.  Sonnenburg's  description  of  this  bath  will  be  found  in  the  Archiv. 
fur  klin.  Chirurgie,  Bd.  28,  p.  921. 


Fig.  123. — Improvised 
apparatus  ^irrigator) 
for  the  imgatiou  of 
a  wound. 


§4'J.j  OTIIEll   DRESSINGS   FOR   WOUNDS.  181 

Cataplasms. — Wai'm  poultices,  either  dry  or  wet,  were  much  used  in  the 
treatment  of  wounds  during  the  preantiseptic  days.  Fomentum,  a  hot,  wet 
api)lifation,  or  a  fomentation  as  it  is  called,  is  derived  from  fovea,  to  warm. 
Cataj)lasin,  or  poultice,  comes  from  the  Greek  word  Karan-A uo-rro),  to  lay  on. 
Fomentations  in  a  dry  form  are  applied  to  the  wound  in  the  shape  of  hot 
cloths,  or  of  tinely  powdered  and  cliopped-u])  herhs  or  vegetable  matter,  such 
as  bean  meal,  bran,  flores  sambucci,  etc.,  either  directly  or  after  being  sewed 
up  in  linen  or  flannel  bags,  etc.  Cataplasms  or  poultices  are  made  of  boiled 
linseed  meal,  groats,  etc.,  which  are  wrapped  in  gauze  or  linen  cloth  before 
applying.  The  ancients  u.sed  a  great  number  of  herbs  of  various  sorts  as 
applications  for  wounds,  and  evinced  a  strong  preference  for  cataplasms  pre- 
pared in  urine  or  from  the  excrement  of  different  domestic  animals.  In  the 
time  of  Aribasius  a  paste  of  figs  and  milk  was  much  in  vogue  on  account  of 
its  antiseptic  action.  At  present,  however,  cataplasms  are  not  considered 
proper  for  the  treatment  of  wounds,  and  w-e  only  use  them  when  we  desire 
to  promote  suj^puration  in  tissues  which  are  infiltrated  with  inflammatory 
matter.  The  preparation  of  poultices  is  very  tedious.  The  hot  poultice  is 
renewed  by  warming  the  wet  cushion  upon  a  hot  plate,  or  in  vessels  made 
for  the  purpose  with  double  walls  between  which  the  water  is  placed  to  sup- 
ply the  moisture,  and  the  vessel  is  then  heated  over  a  gas  or  spirit-lamp 
flame.  For  doing  away  with  this  slow  process  there  have  recently  been 
invented  artificial  cataplasms  about  the  weight  of  thin  pasteboard.  These 
are  soaked  in  hot  water  and  applied  to  the  diseased  portion  of  the  body  and 
covered  over  with  some  water-tight  substance  and  then  with  cotton.  They 
afterwards  swell  and  assume  a  pulpy  consistency.  A  mustard  paper  is  also 
manufactured  which  has  a  very  irritant  effect  upon  the  skin. 

Antiseptic  Poultices. — The  application  to  wounds  of  wet  antiseptic 
poultices  of  mull,  gauze,  lint,  linen,  etc.,  in  a  cold  or  hot  form  is  even 
at  the  present  time  much  used  in  the  treatment  of  suppurating  wounds 
which  are  granulating.  The  lead- water  poultice  is  also  regarded  with 
a  good  deal  of  favour,  and  I  consider  it  a  better  application  than  the 
irritating  one  made  with  carbolic  acid.  The  latter  is  sometimes  used 
too  strong  by  the  laity,  and  also  changed  too  frequently.  I  have  re- 
peatedly seen  gangrene  of  the  skin  on  the  tips  of  the  fingers  caused  by 
carbolic  acid  applied  in  this  form.  If  wet  applications  of  this  kind  are 
to  be  left  in  place  for  some  time,  possibly  one  or  two  days,  and  the  effect 
of  moist  heat  is  desired,  the  applications  should  be  covered  with  rubber 
tissue  over  which  cotton  is  laid,  and  the  whole  dressing  is  then  fastened 
in  position  by  a  bandage  (hydropathic  poultice  or  Priessnitz's  poultice). 
Wet  dressings  like  these,  particularly  if  made  with  lead-water,  have  a 
powerful  stimulating  action  upon  granulations,  and  the  skinning-over 
process  is  occasionally  very  much  hastened.  If  cold  is  aimed  at  in 
the  wet  applications,  for  reduction  of  the  heat  in  any  given  portion  of 
the  body,  the  applications  will  need  very  frequent  renewal. 

Cold — Ice. — In  such  cases  it  is  best  to  use  ice  in  rubber  or  ice  bags, 


182  OTHER   METHODS   OP   TREATING   WOUNDS. 

or  to  add  ice  or  snow  to  the  water  used  for  wetting  the  ]>onltices  ;  or 
else  make  a  coohng  mixture  consisting  of  one  part  ammonium  chlo- 
ride, three  parts  of  nitre,  six  parts  of  vinegar,  and  twelve  to  twenty-four 
parts  of  water  (Schmucker). 

The  effect  of  ice  and  cold  applications  upon  the  wound  is  both 
analgesic  and  haemostatic.  Lately,  Leiter,  of  Vienna,  has  invented  an 
apparatus  for  obtaining  in  the  most  satisfactory  manner  the  effect  of 
cold  and  heat  upon  inflamed  and  injured  portions  of  the  body.  It 
consists  of  a  pliable  metal  tube  through  which  water  at  any  required 
temperature  is  allowed  to  flow.  The  metal  tube  can  be  made  to  as- 
sume any  desired  form,  such  as  a  cap  for  the  head,  or  a  coil  for  encir- 
cling an  extremity,  or  a  flat  piece  for  the  back,  etc.  A  similar  appa- 
ratus has  been  made  of  rubber  tubing,  and  used  as  a  cold  coil  for  an 
extremity,  an  ice  cap  for  the  head,  or  an  ice  bag  for  the  neck. 

Sticking  Plaster. — We  now  treat  small  wounds,  or  those  which  are 
granulating,  by  means  of  a  covering  of  sticking  plaster,  collodion, 
some  ointment,  etc.  Adhesive  plaster  is  made  of  some  substance  like 
linen,  cotton,  silk,  leather,  etc.,  covered  upon  one  side  with  some  such 
sticky  material  as  litharge,  olive  oil,  resin,  or  turpentine,  etc. ;  lead 
plaster  is  made  with  certain  hard  substances — oil,  wax,  turpentine,  etc. 
The  ordinary  German  adhesive  plaster  is  usually  warmed  over  the 
flame  of  a  spirit  lamp  before  being  applied,  and  then  laid  in  strips 
upon  the  desired  portion  of  skin,  which  has  been  previously  dried.  To 
prevent  the  plaster  from  adhering  to  the  hairs,  the  latter  must  be  first 
shaved  off  with  a  razor. 

American  Adhesive  Plaster. — A  very  good  kind  of  sticking  plaster, 
though  somewhat  expensive,  is  the  American  adhesive  plaster  (Ellis's 
adhesive  plaster  cloth),  in  which  the  sticky  material  is  spread  on  muslin, 
linen,  or  silk. 

English  Adhesive  Plaster. — The  English  plaster  adheres  very  well 
and  is  useful  for  small  wounds ;  it  consists  of  fine  sarcenet  having  on 
one  side  a  solution  of  isinglass  and  on  the  other  tincture  of  benzoin 
{Emplastrum  aclhesivmn  anglicum).  The  sticky  side  should  be  mois- 
tened with  some  antiseptic  solution  and  not  with  saliva,  and  then  applied 
to  the  skin. 

Paris  Plaster. — The  Paris  plaster  is  more  flexible  and  adheres  even 
better.  The  recently  invented  iodoform  plaster  consists  of  iodoform, 
glycerine,  and  mucilago  gummi  arabici,  which  is  made  into  a  solution 
and  spread  over  linen. 

There  are  many  other  kinds  of  adhesive  plaster  which  may  be 
found  in  the  Pharmacopoeia. 

Gauze  Adhesive   Plaster. — Unna  has   introduced   a  very  excellent 


§4'J.J  OTllKU   DRESSINGS   FUK   WUL'NDS.  1^3 

gauze  adhesive  plaster,  made  of  oxide  of  zinc  or  iodoform  spread  on 
gauze  with  some  sticky  substance,  and  it  is  often  preferable  to  the  ordi- 
nary adhesive  plaster. 

Collodion. — Of  the  other  adhering  materials  I  should  mention  especially 
collodion,  wlncli  is  a  solution  of  gun  cotton  in  ether  and  alcohol.  By  the 
evaporation  of  the  ether  and  alcohol  the  collodion  dries  in  the  form  of  a  firm 
covering  wliich  adheres  excellently  to  the  skin.  It  is  not  suitable  for  apply- 
ing to  fresh  wounds  on  account  of  the  irritation  it  causes.  Iodoform  collo- 
dion (1  to  10)  is  frequently  used  as  a  protective  dressing,  and  it  is  far  better 
than  adhesive  plaster  in  that  it  does  not  come  off  by  contact  with  water.  A 
cutaneous  wound,  after  it  has  been  sutured,  is  frequently  painted  over  with 
iodoform  collodion  (Kiister,  Zweifel,  Hans  Schmidt),  and  heals  like  any 
wound  sutured  aseptically,  over  which  there  forms  a  dry  aseptic  scab.  Col- 
lodium  elasticum  (collodion  60,  castor  oil  2'5,  turpentine  7'5)  is  particularly 
suited  for  chapped  hands,  frost-bites,  etc. 

Substitutes  for  Collodion. — As  a  substitute  for  collodion  I  use  a  bismuth 
paste — i.  e. ,  a  solution  of  bichloride  to  which  bismuth  has  been  added,  or  zinc 
glue  (oxide  of  zinc  and  gelatine  aa  20  parts  with  distilled  water  and  glycer- 
ine aa  80 "0  parts).  These  dry  rapidly  and  form  an  excellent  covering  for 
sutured  wounds,  as  well  as  for  small,  unsutured,  fresh,  or  granulating  wounds. 

Photoxylin, — Wahl  has  recommended  photoxylin  in  place  of  collodion. 
It  is  a  substance  used  in  photography,  and  he  employs  it  in  a  five-per-cent. 
solution  in  equal  parts  of  alcohol  and  ether. 

Traumaticin. — Traumaticin,  or  a  solution  of  gutta-percha  in  chloroform, 
is  widely  employed  as  an  adhesive  dressing  in  place  of  collodion. 

Gummi  Laccse. — Gummi  laccse  (Mellez)  is  also  much  employed  as  a  sub- 
stitute for  collodion  and  English  adhesive  plaster.  A  solution  of  the  con- 
sistency of  jelly  made  by  adding  alcohol  is  warmed  and  spread  on  cloth,  thus 
forming  a  cheap  and  serviceable  adhesive  plaster  which  is  not  attacked  by 
.  water  or  fat,  etc. 

Salves.— Ointments  as  dressings  for  granulating  wounds  do  not  en- 
joy the  popularity  which  they  once  did,  and  I  rarely  use  them.  I 
prefer,  even  for  granulating  wounds,  antiseptic  dressings,  such  as 
sterilised  gauze  with  or  without  the  addition  of  antiseptic  powders 
like  bismuth,  oxide  of  zinc,  iodoform,  or  similar  substances.  There 
are  a  great  number  of  ointments  of  which  the  principal  ones  are  boric- 
acid  ointment,  boroglycerin  lanolin  (Graf),  vaseline,  salicylic  vaseline, 
carbolised  vaseline  and  glycerine,  ointments  either  pure  or  mixed 
with  various  antiseptics,  and,  *in  addition,  oxide  of  zinc,  lead  oint- 
ments, etc.  An  excellent  base  for  making  ointments  is  the  lanolin 
recommended  by  Liebreicli  in  which  bacteria  cannot  grow.  Glycerine 
fats,  on  the  other  hand,  become  easily  rancid  under  the  influence  of 
light,  and  then  become  a  good  medium  for  the  growth  of  micro-organ- 
isms (Friinkel,  Gottstein). 


184  OTHER  METHODS   OF  TREATING   WOUNDS. 

Mollin. — Kirsten  recommends  mollin  as  an  adjuvant  to  grey  mer- 
curial and  iodine  ointments. 

Pasta  cerata. — In  conclusion,  pasta  cerata  may  be  mentioned 
(Schleich),  which  can  be  used  in  a  variety  of  ways  as  a  dressing  for 

wounds. 


CHAPTER  III. 

GENERAL    RULES    FOR    THE    APPLICATION    OF    BANDAGES    AND    RETENTION 

APPLIANCES. 

The  dififerent  kinds  of  bandages. — The  application  of  the  ordinary  roller  bandage. — 
The  "  reverse." — The  removal  of  bandages. — The  rolling  of  bandages. — The  appli- 
cation of  bandages  to  particular  parts  of  the  body  (head,  neck,  trunk,  upper  and 
lower  extremities). — The  application  of  retention  appliances  to  different  portions 
of  the  body. 


§  50.  Application  of  Bandages. — The  ordinary  bandages  are  made  of 
linen,  liannel.  wel»l)ing,  ur  gauze,  etc.  For  bandaging  wounds,  as  we 
have  said  before,  we  preferably  employ  sterilised  mull  or  stout  gauze, 
which  are  first  soaked  in  a  1  to  1,000  solution  of  bichloride  or  a  three- 
per-cent.  carbolic  solution,  squeezed  dry,  and  then  applied  to  the  se- 
lected portion  of  the  body  in  a  damp  condition,  thus  making  a  well- 
fitting  and  strong  permanent  dressing,  as  illustrated  in  Figs.  IIS  and 
119,  on  page  152. 

The  rubber  bandage,  made  from  ordinary  caoutchouc,  or  the  band- 
age of  elastic  webbing  is  used  when  it  is  desired  to  apply  a  dressing  to 
exert  pressure.  Elastic  bandages  are  adapted  for  application  about  the 
thorax,  the  abdomen,  etc.,  where  other  band- 
ages become  easily  displaced  and  loosened. 
There  are  both  single  and  double  roller  band- 
ages, the  latter  being  illustrated  in  Fig.  121 ; 
triple  and  quadruple  rollers  were  formerly 
much  in  yogue,  and  can  be  easily  made  by 
fastening  together  a  couple  of  ordinary  band- 
ages. The  many-tailed  bandage,  as  it  is  called,  consists  of  several  strips 
of  bandage  overlapping  laterally  and  joined  in  the  centre  by  a  single 
cross  strip. 

Application  of  the  Roller  Bandage. — The  ordinary  roller  bandage  is 
applied  by  holding  the  end  of  the  bandage  upon  the  desired  spot  with 
the  index  finger  or  thumb  of  the  left  hand,  while  the  roller  is  directed 
upward  (Fig.  125).  The  first  turn  of  the  bandage  is  secured  by  a 
second,  making  two  thicknesses  of  the  bandage  at  the  one  place ;  then 

(185) 


¥h 


124. — Don  1  lie  roller 
bandaire. 


186    APPLICATION   OP   BANDAGES  AND   RETENTION  APPLIANCES. 

the  bandage  is  unrolled  spirally  upwards  about  the  part,  making  each 
upper  turn  overlap  about  half  of  the  width  of  the  one  next  below,     I 

usually  wind  the  bandage 
from  left  to  right.  If  it  is 
desired  to  rapidly  secure  a 
dressing  in  place,  each  spiral 
turn  may  be  separated  by  a 
considerable  distance  from 
the  next  lower  turn  (Fig. 
12G),  and  subsequently  the 
bandage  may  be  completed 
in  the  regular  way.  If  one 
attempts  to  apply  a  linen  or 
gauze  bandage,  for  example, 
to  the  upper  or  lower  ex- 
tremity, with  circular  or 
spiral  turns,  it  will  soon  be  noticed  that  the  lower  edge  of  each  turn 
does  not  fit  tightly  to  the  extremity,  and  that  its  "  set,"  particularly  in 
the  case  of  the  forearm  and  leg,  is  uneven.  For  preventing  this  loose- 
ness of  the  lower  margin  of  each  turn,  and  to  make  the  whole  bandage 
fit  evenly  and  firmly,  it  is  customary  to  make  what  is  called  a  "  reverse," 
which  is  best  done  as  follows  (Fig.  127) :  1.  The  roller  is  grasped  by 
the  right  hand  in  such  a  way  that  one  looks  into  the  palm  of  the  hand, 
the  dorsal  surface  is  directed  downwards,  and  the  bandage  drawn  tight 
and  smooth  obliquely  upwards,  while  its  lower  edge  is  held  firm  by 
the  left  thumb  (Fig.  127,  a).  2.  The  traction  on  the  obliquely  directed 
portion  of  the  bandage  beyond  the  left  thumb  is  then  relaxed  (Fig. 


Fig.  125. — Application  of  the 
ordinary  roller  bandage. 


Fig.  126.— Spiral 
bandasje. 


Fig.  127. — Application  of  the  reverse  bandage. 


127,  I).  3.  The  upper  edge  of  the  bandage  is  then  folded  over  down- 
wards (Fig.  127,  c).  The  points  of  reverse  should,  as  far  as  possible,  be 
made  at  the  same  part  of  the  circumference  of  the  extremity,  and  lie 
one  above  the  other.     This  method  should  be  employed  not  only  in 


*5  50.] 


APPLICATION    OP   BANDAGES. 


187 


bandaging  an  extreuiity,  but  any  other  i)ortion  of  the  body,  so  as  to 
make  the  turns  of  the  bandage  lit  into  the  inequalities  of  the  particular 
locaHty.  The  iKiiuhige  is  usually  completed  by  one  or  two  circular 
turns.  AVhile  making  tiic  reverses  care  should  be  taken  that  ridges  and 
folds  are  not  allowed  to  form.  Considerable  practice  is  necessary  in 
order  to  be  able  to  put  one  on  quickly  and  accurately.  The  end  of  the 
bandage  should  be  fastened  in  place  with  a  safety-pin,  or  it  may  be 
slit  up  at  the  end  with  scissors,  or  simply  torn  lengthwise  in  the  mid- 
dle, if  it  is  a  nmslin  or  gauze  bandage,  and  the  split  ends  carried  around 
the  extremity  in  opposite  directions  and  knotted  together. 

A  bandage  is  taken  oil  by  unwinding  the  turns  in  the  reverse  direc- 
tion to  wliicli  they  were  put  on — i.  e.,  the  turn  last  applied  is  the  first 
to  be  taken  oif.  At  the  same  time  the  bandage  is  rolled  up,  and  during 
the  unwinding  is  quickly  passed  from  one  hand  into  the  other.  The 
removal  of  a  mull  or  gauze  bandage  is  generally  accomplished  by  simply 
slitting  it  up  with  bandage  scissors. 

In  Fig.  128  is  illustrated  the  method  of  rolling  a  bandage.  Mull 
and  gauze  bandage  rolls  are  best  and  most  rapidly  made  by  means  of  a 
small  rolling  machine. 

Application  of  a  Bandage  to  the  Head. — The  method  of  applying 
bandages  to  the  head  is  illustrated  in  Figs.  129-132. 


Fig.  128. — Rollincr  a  bandaffe. 


Fig.  129. — Fascia  nodosa.     Fig.  130. — Mitra  Ilippocratis. 


Fig.  129  represents  the  fascia  nodosa  or  knotted  bandage.  The 
middle  of  a  strip  of  bandage  is  laid,  for  example,  on  the  left  temple, 
and  one  end  of  the  strip  is  carried  over  the  crown,  the  other  under  the 
chin  to  the  right  temple,  and  at  this  point  the  two  ends  are  crossed, 
the  one  which  came  from  under  the  chin  passing  around  the  forehead, 
the  other  around  the  occipital  region,  and  the  two  ends  are  then  knotted 
together.  The  principle  of  this  knotted  bandage  can  be  used  with 
some  variations  for  almost  any  desired  portion  of  the  body.  Its  chief 
use  is  for  exerting  pressure  on  some  particular  spot,  which  can  be  in- 
creased by  inserting  beneath  the  bandage  a  pad  of  cotton  or  gauze,  etc. 


188  APPLICATION   OP   BANDAGES   AND   RETENTION   APPLIANCES. 

It  is  also  used  in  the  inguinal  region  (Fig.  157),  as  a  temporary  substi- 
tute for  a  hernia  truss. 

Mitra  Hippocratis. — The  mitra  Hippocratis  (Fig.  130)  is  made  with  a 
double  roller,  or,  what  is  simpler,  with  an  ordinary  roller  bandage.  When 
the  double  roller  is  employed  its  centre  is  applied  in  the  middle  of  the 
forehead,  one  roller  being  carried  horizontally  around  the  head  towards 
the  right,  the  other  towards  the  left,  and  at  the  occiput  the  two  rollers 
are  crossed  in  the  manner  of  the  fascia  nodosa ;  then  an  assistant  car- 
ries one  roller  over  the  crown  to  the  forehead,  while  the  operator,  with 
the  second  roller,  takes  a  circular  turn  horizontally  around  the  head 
and  crosses  the  roller,  which  has  been  carried  over  the  crown,  upon  the 
forehead.  This  is  continued,  one  roller  being  carried  from  the  fore- 
head to  the  occiput  and  then  back  again  to  the  forehead,  first  on  the 
riglit  side  and  then  on  the  left  of  the  original  median  strip  carried 
sagittally  over  the  crown,  each  circular  turn  of  the  other  roller  securing 
the  strips  passing  over  the  crown.  The  entire  skull  is  thus  covered 
with  strips  of  bandage  running  forwards  and  back  in  a  sagittal  direction. 
Finally,  the  ends  of  both  rollers  are  carried  circularly  around  the  head 
and  fastened  in  place  with  a  safety-pin.  The  mitra  Hippocratis  is  only 
occasionally  applied  with  a  double  roller,  but  it  is  well  to  understand 
the  principle  of  it  in  treating  wounds  of  the  head  antiseptically  (see 
page  152,  Fig.  118).  A  mull  or  wet  gauze  bandage  may  be  applied  to 
the  skull  partly  with  circular  turns  and  partly  with  turns  passing  back 
and  forth  in  the  sagittal  direction  over  the  top  of  the  head. 

Capistrum  Duplex. — The  capistrum  duplex  is  not  very  often  used 
now,  but  it  was  at  one  time  in  great  repute  for  treating  fractures  of  the 
lower  jaw,  as  was  also  the  capistrum  simplex.     The  funda  maxillse 
(Fig.  148)  has  the  same  effect  as  the  capistrum  simplex 
and  duplex,  and  is,  furthermore,  much  better  and  sim- 
pler.    Some  of  the  turns  made  in  the  capistrum  duplex 
are  used  for  applying  antiseptic  dressings  to  the  head 
and   neck,  and  hence   it  should    be  spoken   of    here. 
The  description  of  the  old-fashioned  capistrum   sim- 
plex will  be  omitted.     The  capistrum  duplex  is  begun 
with  the  end  of  the  roller  on  the  vertex,  then  it  passes 
Fig.  131.  down  in  front  of  the  left  ear,  under  the  chin,  and  up 

Capistrum  duplex.       _  _  _  ^ 

in  front  of  the  right  ear  to  the  vertex  again ;  then 
from  this  point  it  passes  around  the  occiput  to  the  right  side  of  the 
neck,  under  the  chin,  and  up  in  front  of  the  left  ear,  covering  the  first 
turn  in  great  part,  back  to  the  vertex  again  ;  then  around  the  occiput  to 
the  left  side  of  the  neck,  beneath  the  chin,  and  up  in  front  of  the  right 
ear  to  the  vertex.     In  this  way  three  turns  of  the  bandage  are  made  in 


§  50.; 


APPLICATION   OF   BANDAGES. 


189 


front  of  each  ear,  and  then  it  is  carried  from  the  neck  in  front  of  the 
chin  and  the  lower  part  of  the  under  lip,  and  is  finally  tenninated  hy 
a  circular  turn  around  the  forehead  and  occiput.  The  cii-cular  turn 
around  the  front  of  the  chin  can  be  made  between  the  second  and  third 
turns  taken  in  front  of  the  ear.  In  ap])lyini;  an  anti- 
septic dressing  the  neck  should  also  be  included  in  the 
bandage. 

Monoculus  and  Binoculus. — Fig.  132  represents  the 
method  of  ajiplying  the  monoculus,  which  begins  with 
a  circular  turn  about  the  head,  starting  from  the  tem- 
poral region.  The  rest  can  be  understood  from  Fig. 
132.  The  so-called  binoculus,  or  bandage  over  both 
eyes,  is  performed  by  first  covering  one  eye  with  a 
circular  turn  of  the  bandage  and  then  carrying  the 
bandage  with  obliquely  descending  turns  over  the  other  eye. 

Application  of  a  Bandage  to  Neck  and  Thorax. — The  application  of 
bandages  to  the  neck  is  accomplished  by  making  circular  turns,  to 
which,  in  the  case  of  large  wounds,  are  added  cross  turns  under  the  ax- 
illa and  over  the  shoulder  (see  page  152,  Fig.  119).  Bandages  are  ap- 
plied to  the  thorax  by  circular  turns,  with  or  without  reverses.  To 
keep  the  bandage  from  becoming  displaced,  every  other  turn  can  be 
carried  from  the  back  over  the  shoulder  and  secured  with  safety-pins 
at  the  points  of  meeting  with  the  horizontal  turns  ;  or  the  circular 
turns  may  be  made  to  ascend  from  below  upwards  on  the  tliorax,  and 
finished  by  oblique  turns  about  the  shoulder  and  axilla  like  a  spica 
humeri  (Fig.  138,  a  and  b).  For  bandaging 
a  wound,  after  applying  a  thick  cushion  of 
di-essings,  we  employ  starch  bandages, 
which,  after  drying,  fit  closely  and  do  not 
become  easily  displaced.  Elastic  bandages 
are  also  to  be  recommended  for  the  trunk, 
as  they  retain  their  position  very  well. 

Bandaging  of  the  Mamma.  Suspensori- 
um  Mamtnce  Shnplex  (Fig.  133). — The 
bandage  for  the  right  mamma  is  begun  by 
a  circular  turn  about  the  lowermost  portion 
of  the  thorax.  The  bandage  is  then  car- 
ried obliquely  so  as  to  envelop  the  lower 
part  of  the  gland,  over  the  opposite  shoulder,  then  across  the  axilla,  over 
the  shoulder  and  across  the  back,  again  to  the  right  breast  at  its  upper 
part,  and  then  once  more  over  the  shoulder,  etc.  The  upper  and 
lower  portion  of  the  gland  is  crossed  alternately,  and  then  its  middle 


Fig.  133. — Suspensorium  maminffi 
duplex  and  small  outer  bandage 
for  the  mamma. 


190  APPLICATION  OF  BANDAGES  AND  RETENTION  APPLIANCES. 


part,  and  finally  the  bandaging  is  completed  by  a  circular  turn  around 
the  lowermost  portion  of  the  thorax  covering  the  preliminary  turns 
(Fig.  133).  The  suspensorium  mamms  duplex  and  a  light  supporting 
bandage  for  both  breasts  can  be  applied  very  simply  by  using  the 
method  illustrated  in  Fig.  133  on  both  sides. 

Antiseptic  Retention  Dressing  after  Amputation  of  the  Breast  and 
cleaning  out  the  Axilla. — After  amputation  of  the  breast,  accompanied 

by  cleaning  the  carcinomatous 
lymphatic  glands  out  of  the  axilla, 
I  first  put  on  a  dressing  of  sev- 
eral layers  of  sterilised  gauze 
placed  in  direct  contact  with  the 
wound,  then  over  this  I  apply 
absorbent  cotton  or  pads  of  jute, 
covering  in  the  shoulders  and  en- 
tire thorax.  These  materials  are 
then  bound  on  by  a  sterilised 
mull  bandage  encompassing  the 
thorax,  neck,  and  shoulders,  the 
edges  of  the  dressings,  particular- 
ly in  the  axilla,  neck,  and  at  the 
lower  border  of  the  breast,  be- 
ing very  carefully  filled  in  with 
absorbent  cotton  ;  then  the  arm 
on  the  side  which  has  been  operated  upon  is  placed  in  contact  with  the 
thorax  and  also  covered  with  sterilised  absorbent  cotton.     After  this 

the  arm  is  immobilised  by  a 
disinfected  mull  and  finally  a 
gauze  bandage  encircling  the 
thorax,  neck,  and  shoulder 
(Fig.  1341 

Application  of  Bandages  to 
the  Upper  Extremity.  —  The 
methods  of  applying  bandages 
to  the  fingers  are  illustrated 
in  Fig.  135,  «,  5,  c.  They 
are  begun  with  a  circular  turn 
around  the  wrist,  and  then 
carried  across  the  dorsum  of 
the    hand    to    any    particular 


Fig.  134. — Aseptic  dressinir  t'ur  iix- 
putatio  maminiB  with  uieauiu" 
left  axilla. 


utter  an  arn 
out    of   tlie 


Fig.  135.— Application  of  bandages  to  the  fingers. 


finger,  and,  after  encircling  it,  brought  back  again  to  the  back  of  the 
wrist  (Fig.  135,  a).     A  finger  can  be  bandaged,  as  illustrated  for  the 


§50.] 


APPLICATION   OF   BANDAGES. 


191 


little  finger  in  Fig.  135,  c,  by  making  oblique  .s})iral  turns  down  to  its 
tip,  and  then  covering  in  the  finger  by  oblique  or  circular  turns  from 
tip  to  base.  The  finger  bandage 
can  also  be  carried  iu  the  reverse 
direction,  beginning  on  the  finger 
and  terminating  at  the  wrist.  More- 
over, the  thumb  may  be  bandaged 
in  the  way  pictured  in  Fig.  135,  h  ; 
beginning  wifh  a  circular  turn 
around  the  wrist,  the  bandage  is 
carried  to  the  tip  of  the  thumb,  and 
around  this,  over  the  back  of  the 
hand,  and  so  on,  with  oblique  turns 
till  the  base  of  the  thumb  is  reached. 
If  it  is  desired  to  bandage  the  tip  of 
the  finger,  the  roller  is  carried  along 
the  back  or  palmar  surface  of  the  finger  over  its  tip  and  back  on  the 
other  side  opposite  the  starting-point,  where  it  is  retained  while  a  cir- 
cular turn  is  made  around  the  base  of  the  finger,  over 
the  ends  of  the  loop,  securing  it  in  its  position.  A 
bandage  is  applied  to  the  whole  hand  according  to  the 
rules  for  the  spica  manus  (Fig.  136).  The  bandage  is 
started  at  the  wrist  by  a  circular  turn,  and  then  oblique 
or  figure-of-eight  turns  are  taken  by  the  roller,  grad- 
ually   proceeding    downwards     till    the    finger    ends 


Fig.  13G. 
Spica  luanus. 


Fig.  137.— Bandage  for 
tlie  hand. 


Fig.  138. — a,  Spica  humeri 
a.scendens. 


J,  Spica  humeri  deseendens 


Fig.  139. — Bandage 
for  the  entire  up- 
per extremity. 


are  reached.     It  is  concluded   with  a  circular  turn  about  the  wrist. 

Another  way  of  bandaging  the  hand  is  represented  in  Fig.  137,  a 

and  h.     It  is  begun  with  a  circular  turn  around  the  wrist  (Fis:.  137.  a) 


192  APPLICATION   OP   BANDAGES   AND   RETENTION   APPLIANCES. 


or  around  the  ends  of  the  fingers,  and  proceeds  up  or  down  with  figure- 
of-eight  or  obhque  turns,  half  of  the  width  of  each  upper  turn  overlap- 
ping a  corresponding  amount  of  the  next  lower  turn,  and  finally  termi- 
nating with  a  circular  turn  around  the  finger  tips  or  the  wrist.  If  it  is 
desired  to  include  the  finger  tips,  as,  for  instance,  in  an  antiseptic  pro- 
tective dressing,  the  end  of  the  bandage  is  secured  while  the  roller  is 
carried  over  and  around  the  ends  of  the  fingers  and  back  on  the  oppo- 
site side  in  the  form  of  a  loop,  and  the  extremities  of  the  loop  are  then 
fastened  in  place  by  a  circular  turn. 

Application  of  a  Bandage  to  the  Shoulder. — The  shoulder  is  bandaged 
by  using  the  spica  humeri  ascendens  (Fig.  138,  a)  or  descendens  (Fig. 
138,  h).  The  spica  humeri  ascendens  (Fig.  138,  a)  begins  with  a  circu- 
lar turn  around  the  upper  end  of  the  arm,  the  bandage  being  then  car- 
ried over  the  lower  end  of  the  shoulder  from  within  outward,  then  over 
the  back  to  the  opposite  axilla  and  back  again  across  the  breast  over  the 
shoulder  through  the  axilla,  and  finally  terminated  by  a  circular  turn 
around  the  thorax.  The  spica  humeri  descendens  (Fig.  138,  h)  is  applied 
in  the  reverse  direction— i.  e.,  it  is  begun  with  a  couple  of  circular  turns 
about  the  thorax,  and  finished  with  descending  oblique  or  cross  turns 
over  the  shoulder,  terminating  on  the  arm  lower  down,  or  with  a  circu- 
lar turn  about  the  thorax  again.  Fig.  139  represents  the  method  of 
applying  a  bandage  to  envelop  the  whole  arm.  The  turns  of  the  spica 
humeri  around  the  thorax  are  omitted  in  the  illustration  in  order  to 
economise  space,  but  the  rest  of  the  figure  illustrates  the  bandage  for 
the  entire  upper  extremity. 

Application  of  Bandages  to  the  Lower  Extremity. — The  bandage  for 
the  lower  extremity  is  begun  by  enclosing  the  foot  (Fig.  140,  a  and  h) 
by  a  circular  turn  made  back  of  the  toes,  as  illustrated  in  Fig.  140,  a  y 

then  two  or  three  slightly  ol)li(}ne 
turns  are  taken,  with  or  without 
the  reverse  (Fig.  127),  and  at 
about  the  fourth  turn  of  the 
bandage  the  latter  is  cari'ied  ob- 
li(]uely  over  the  anterior  aspect 
of  the  ankle-joint  toward  the  in- 
ternal malleolus,  and  from  here 
over  the  heel  and  around  the 
outer  malleolus  again  to  the  inner 
side  of  the  foot ;  thence  across 
the  sole,  making  two  or  three  stirrup  turns,  and  then  ascending  the  leg 
with  circular  turns,  followed  by  oblique  turns  and  the  reverse  (Fig. 
127).     If  the  heel  is  to  be  included  (Fig.  140,  5),  the  bandage  is  begun 


Fig.  140. — Applioation  of  bandages  to  tlie  foot. 


^  r,o.j 


APl'LU'ATION   OK    BANDAGES. 


193 


as  in  Fig.  1-iO,  a  ;  but  after  taking  two  or  three  turns,  it  is  carried  across 
the  dorsum  of  the  foot  to  tlie  heel,  around  the  latter,  over  the  dorsum 
to  the  inner  side  of  the  foot,  thence  across  the  sole  to  the  outer  side  of 
the  foot,  again  over  the  dorsum  to  tiie  heel,  each  preceding  turn  being 
covered  by  half  the  width  of  the  following  turn,  and  so  on  till  above 
the  ankle,  when  two  circular  turns  are  made,  and  then  these  are  suc- 
ceeded by  obli(|ue  turns  with  reverses  ascending  the  leg. 

For  ap])lying  a  bandage  to  the  regioTi  of  the  knee-joint  the  testudo 
inversa  (Fig.  1-il,  a  and  b)  or  reversa  (Fig.  142,  a  and  h)  is  used.     In 


Fig.  141. — Testudo  inversa  genua. 


Fig.  142. — Testudo  reversa  jjenus. 


the  testudo  inversa  (Fig.  141),  after  several  circular  turns  are  made 
around  the  leg,  an  oblique  turn  is  carried  across  the  popliteal  space 
toward  the  thigh,  passing  around  the  latter  back  across  the  popliteal 
space  to  the  leg  and  so  on  gradually  covering  in  first  the  lower,  then 
the  upper  part  of  the  anterior  aspect  of  the  knee,  the  last  turn  crossing 
the  centre  of  the  anterior  aspect  of  the  knee  transversely  (Fig.  141,  h). 
The  testudo  reversa  is  begun  with  a  circular  turn  around  the  middle 
of  the  knee,  and  the  remaining  turns  are  made  obliquely,  first  above 
and  then  below  the  original  circular  turn. 

The  testudo  bandage  is  also  employed  for  the  elbow. 

When  it  is  desired  to  wrap  the  entire  lower  extremity  in  a  bandage, 
the  region  of  the  knee  may  be  covered  simply  by  circular  turns  (Fig. 
145).  The  hip,  in  the  same  way  as  the  shoulder,  may  be  bandaged  by 
a  spica  coxfe  ascendens  (Fig.  143)  or  descendens  (Fig.  144).  The  spica 
Goxse  ascendens  is  begun  with  a  circular  turn  around  the  upper  part  of 
the  thigh,  and  then,  in  the  case  of  the  left  hip,  the  bandage  is  carried 
across  the  gluteal  and  sacral  region  towards  the  opposite  anterior  supe- 
rior spine  of  the  ilium,  thence  over  the  lower  part  of  the  abdomen  and 
inguinal  region  back  to  the  thigh.  For  the  right  thigh,  the  bandage  is 
carried  over  the  groin  and  abdomen  to  the  anterior  superior  spine, 
U 


194  APPLICATION   OF   BANDAGES  AND   RETENTION    APPLIANCES. 


thence  across  the  sacral  and  ghiteal  regions  back  to  the  thigh.     Each 
succeeding  turn  ascends  a  little  higher  on  the  thigh,  and  the  bandage 
is  finally  completed  by  a  circular  turn  around  the 
abdomen.     The  spica  coxae  descendens  (Fig.  144)  is       h 
begun  where  the  ascendens  terminates,  by  circular 


Fig.  143. — Spica  co.xae 
ascendens. 


Fig.  1M. — Spica  coxae 
descendens. 


Fig.  145.  —  Bandage 
for  the  entire  low- 
er extremity. 


turns  around  the  abdomen,  and  is  made  to  descend  by  oblique  turns  in 
a  manner  the  reverse  of  the  spica  ascendens,  and  finally  to  come  down 
the  thigh  by  circular  and  oblique  turns  made  with  reverses.  The 
method  of  bandaging  the  entire  lower  extremity  will  be  understood 
from  the  previous  remarks  (Fig.  145). 

§  51.  Application  of  suitably  shaped  Pieces  of  Cloth  in  place  of  Band- 
ages.— Properly  shaped  pieces  of  cloth  as  substitutes  for  bandages  are 


Fig.  146.— Double  piece  of  cloth ; 
bandage  to  support  the  jaw. 


Fig.  147. — Handkerchief  or  impromptu 
cloth  bandage  for  the  jaw. 


Fig.  148. 
Funda  maxillae. 


not  suitable  for  dressing  wounds  antiseptically,  but  under  other  cir- 
cumstances— viz.,  for  applying  a  light  protective  dressing,  or  for  the 
after-treatment  of  a  wound,  or  in  an  emergency — they  do  very  well,. 


§51.]  HANDKERCIIIKF    fJANDAGES.  J95 

and  possess  tlie  advantage  that  the  material  for  making  them  can 
always  be  obtained  in  every  houseliold.  These  bandage  substitutes 
are  made  of  triangular  or  quadrilateral-shaped  pieces  of  cloth.  One 
of  the  most  useful  of  these  bandage  substitutes  is  the  sling  bandage. 
The  base  or  longest  of  the  three  sides  of  a  triangular  piece  of  cloth  is 
cut  in  the  manner  indicated  by  the  dotted  lines  in  Fig.  146,  thus  mak- 
ing a  five-tailed  piece  of  cloth,  which  is  excellent  as  a  bandage  for 
the  inferior  maxilla  (Fig.  148).  Another  very  good  bandage  substitute 
may  be  made  by  splitting  the  smaller  sides  of  a  long  rectangular  piece 
of  cloth  and  ap))lying  it  as  a  bandage  for  the  head  in  the  manner  indi- 
cated in  Fig.  147,  a  and  b. 

These  pieces  of  cloth  used  as  bandage  substitutes  may  either  be 
folded  up  in  the  shape  of  a  cravat  and  made  to  encircle  any  part  of 
the  body,  or  they  may  be  used  as  simple  unfolded  pieces  of  cloth. 
The  folded  strips  are  applied  like  any  ordinary  roller  bandage.  For 
the  sake  of  brevity  I  shall  confine  myself  to  the  following  short  de- 
scription of  the  different  methods  of  using  these  substitutes  for  roller 
bandages. 

As  regards  the  head,  a  triangular  piece  of  cloth  folded  into  the 
shape  of  a  cravat  is  an  excellent  substitute  for  the  monoculus  in  band- 
aging the  eye,  and  for  making  a  horizontal  bandage  on  the  forehead 
like  the  fascia  nodosa  (Fig.  129).  A  very  useful  bandage  as  a  tem- 
porary dressing  for  a  fracture  of  the  upper  or  lower  jaw  is  the  funda 
maxillae  (Fig,  148),  which  is  made  from  the  five-tailed  sling  bandage 
represented  in  Fig.  146.  The  three-cornered  piece  is  folded  up  like  a 
cravat,  the  middle  of  which  is  placed  under  the  chin  of  the  patient, 
and  the  two  ends  are  knotted  together  upon  the  top  of  the  head.  The 
point  of  meeting  of  the  other  two  tails  is  held  in  front  of  the  chin,  and 
the  ends  of  these  tails  carried  around  the  back  of  the  neck,  where  they 
are  crossed  and  brought  forward  and  knotted  together 
on  the  forehead.  Mention  should  also  be  made  of  the 
capitium  parvum,  magnum,  and  quadrangulare. 

The  Small  Head-dress  {Capitium  parvum,  Fig. 
149). —  An  ordinary  triangular  piece  of  cloth  is  laid 
over  the  head,  with  the  centre  of  its  longest  side  at 
the  root  of  the  nose,  and  its  apex  or  angle  opposite 
the  longest  side  hanging  down  the  neck.  The  lateral 
tails  of  the  triangle  are  carried  around  the  neck  back  Fig.  149. 

to  the  forehead,  where  they  are  tied  together.     The 
tail  hanging  down  the  neck  is  turned  back  over  the  top  of  the  head  and 
secured  with  a  safety-pin. 

The  Large  Head-dress  {Capitium.  magnum,  Fig.  150). — The  triangu- 


196  APPLICATION   OF   BANDAGES   AND   RETENTION   APPLIANCES. 


lar  sling  bandage  is  cut  in  the  manner  represented  in  Fig.  146  and  laid 
on  the  scalp,  with  the  centre  of  its  longest  side  at  the  root  of  the  nose. 


Fig.  150.— Large 
handkerchief  band- 
age for  the  head. 


Fig.  151. — Capitium  quadrangulare. 


The  two  anterior  tails  hanging  down  on  each  side  of  the  face  are 
passed  around  the  neck,  as  in  the  capitium  parvum,  and  brought  for- 
wards and  knotted  together  on  tlie  forehead.  The  other  two  tails  are 
tied  under  the  chin,  and  the  apex  of  the  triangular  piece  of  cloth  is 
finally  brought  forwards,  as  in  the  capitium  parvum,  from  beneath  the 
tails,  crossed  behind  the  neck,  and  secured  in  front  by  a  safety-pin. 

The  Four-tailed  Head-dress  {Capitium  quadrangulare,  Fig.  151,  a). 
— A  quadrilateral  piece  of  cloth  is  so  folded  over  the  top  of  the  head 
that  its  under  border  overlaps  the  upper  by  about  a  handbreadtli  (Fig. 
151,  a).  The  two  upper — or,  rather,  posterior — angles  are  knotted  to- 
gether under  the  chin,  while  the  other  two  corners  are  drawn  some- 
what forwards  and  upwards.     Then  the  projecting  lower  edge  of  the 

under  portion  of 
the  cloth  is 
turned  up  and 
back,  and  the 
two         anterior 


corners  are  car- 
ried around  be- 
liind  the  neck 
and  tied,  thus 
I  forming  the 
'  bandage     repre- 

Fio.  153. — Handkerchief  bandage      SCUtcd     in      Fig. 
for  the  breast.  , 

151,  0. 

An  ordinary  three-cornered  piece  of  cloth  can  be  applied  to  the 

thorax  in  the  manner  illustrated  in  Fig.  152.     The  longest  side  of  the 

triangle  is  placed  around  the  lower  portion  of  the  thorax,  while  the 


Fig.  152. 


—Handkerchief  bandage 
for  the  breast. 


§51.J 


HANDKERCHIEF  BANDAGES. 


197 


apex  or  opposite  angle  of  the  triangle  is  carried  over  either  the  right 
or  left  shoulder  and  tied  to  the  other  two  tails  or  angles  of  the  triangle 
behind. 

In  suitable  cases  a  bandage  may  be  applied  as  in  Fig.  153 — i.  e.,  a 
folded  piece  of  cloth  is  i)laced  around  the  thorax  and  prevented  from 
becoming  displaced  by  a  cou})le  of  retention  straps  carried  over  the 
shoulders  and  having  their  junctions  with  the  breast-piece  secured  by 
safety-pins.  The  female  manuna  can  be  supported  by  an  ordinary 
triangular  piece  of  cloth,  or  one  made  double,  as  shown  in  Fig.  146. 
The  sling  is  applied  with  the  centre  of  the  base  of  the  triangle  beneath 
the  breast  which  it  is  desired  to  support.  Then  the  lower  tails  or  cor- 
ners at  each  side  of  this  point  are  carried  around  the  thorax,  while  the 
other  three  tails  are  conducted  across  the  axilla  and  over  both  shoulders 
to  the  back,  whez'e  they  are  tied  together. 


Fig.  154. — Ilandkercliiet'  bandage 
for  supporting  the  mamma. 


Fig.  155.— Mitella. 


The  triangular  piece  of  cloth  is  very  frequently  used  for  making 
the  so-called  mitella,  or  arm  support  (Fig.  155).  The  following  is  the 
method  for  applying  the  mitella :  The  three-cornered  piece  of  cloth  is 
grasped  at  each  extremity  of  one  of  the  shorter  sides  and  placed  be- 
tween the  thorax  and  the  arm  bent  at  right  angles,  with  one  angle  of 
the  triangular  cloth  projecting  around  back  of  the  elbow.  The  upper 
end  of  the  longest  side  is  then  carried  over  the  opposite  shoulder  and 
tied  to  the  other  end  of  the  longest  side  behind  the  neck.  The  third 
corner  or  angle  of  the  triangular  cloth  is  carried  around  the  back  of  the 
elbow  to  the  front  and  secured  in  this  place  by  a  safety-pin  (Fig.  155,  a). 
Instead  of  bringing  this  third  angle  around  in  front  of  the  elbow,  it 
can  be  turned  in,  and  then  the  two  edges  of  the  sling  can  be  pinned  be- 
hind the  arm,  as  represented  in  Fig.  155,  h.  Moreover,  it  is  a  very  good 
plan  not  to  tie  the  ends  of  the  sling  around  the  neck,  as  the  knot  causes 
discomfort,  but  to  bring  the  extremities  to  the  front  again,  and  either 
sew  or  pin  them  in  that  position. 


19S  APPLICATION   OF   BANDAGES  AND   RETENTION  APPLIANCES. 

A  four-tailed  or  four-cornered  piece  of  clotli  can  be  used  for  a  sling, 
like  the  mitella,  but  the  manner  of  its  application  is  more  complicated, 
without  being  any  better. 


Fig.  156. — Handkerchief 

bandage  for  the  shoulder  or 

axilla. 


Fio.  157.— Knotted  bandage 
about  the  inguinal  region. 


Fig.  158. — Handkerchief 

bandage  about  tlie  inguinal 

rey-ion. 


Strips  of  bandage  can  be  used  instead  of  the  mitella.  They  are 
fastened  to  the  coat  or  tied  around  the  neck.  An  ordinary  sling  can 
be  made  for  the  arm,  with  a  couple  of  suspensory  strips  attached  to  en- 
circle the  neck,  or  the  forearm  can  be  bent  at  right  angles  and  the  hand 
inserted  in  the  waistcoat  or  partially  buttoned  coat. 

In   Figs.  156  to  160  are   represented  the   methods  for  applying 
pieces  of  folded  cloth  around  the  axilla  or  the  shoulder,  about  the  in- 
guinal region,  the  hand,  and  foot,  and  they  need  no  further  explana- 
tion.    In  Fig.  157  the  principle  of  the  fascia  nodosa  is 
used  (Fig.  129) — i.  e.,  the  ends  of  the  ])andage  are  twisted 


Fig.  159.— Hand- 
kerchief band- 
aj'e  for  the  hand. 


Fig.  160. — Handkerchief  band- 
age for  the  foot. 


Fig.  161.— Hand- 
kerchief bandage 
for  the  hand. 


Fig.  16 '2.— Handker- 
chief bandage  for 
the  foot. 


about  each  other  for  exerting  pressure  upon  some  particular  spot.  By 
means  of  a  pad  of  cotton,  lead,  rubber,  or  other  material,  the  pressure 
can  be  increased. 


§51.]  HAXDKKRCrilEP   BANDAGES.  *  I99 

In  Figs.  159  and  UIO  are  represented  the  methods  of  applying  a  band- 
age substitute  to  the  hand  and  foot.  The  hand  is  wrapped  in  a  three- 
cornered  piece  of  cloth  in  the  following  manner  (Fig.  KJl) :  The  centre 
of  the  base  of  the  triangle  is  placed  at  the  wrist,  while  the  angle  oppo- 
site the  base  projects  a  little  beyond  the  tips  of  the  fingers.  This  pro- 
jecting angle  is  then  turned  back  over  the  fingers  and  dorsum  of  the 
hand  to  the  wrist,  the  lateral  angles  are  given  a  turn  around  the  wrist 
and  made  to  cross  each  other  on  the  dorsum  of  the  hand,  then  brought 
back  to  the  wrist  and  tied.  The  same  idea  is  carried  out  on  the  foot, 
but  instead  of  knotting  the  ends  around  the  leg,  they  can  be  carried 
back  from  the  leg  and  crossed  over  the  dorsum  of  the  foot,  and  finally- 
tied  after  making  a  circular  turn  around  the  foot  (Fig.  162). 


CHAPTEK  lY. 

THE    SICK-BED    OF    THE    PATIENT. — IMMOBILISATION    APPLIANCES    AND 

DRESSINGS. 

The  sick-bed  of  the  patient. — The  bed. — Adjustable  beds. — Bed  fittings  :  Air-cushions; 
water-cushions. — Supports. — Wire  cradles. — Appliances  for  lifting  patients. — Ap- 
pliances for  the  sick-bed:  Cushions;  straw  splints. — Planum  inclinatum  simplex 
and  duplex. — Petit's  leg  splint. — Suspension. — Wire  gutters  and  baskets. — Splints. 
— Materials  for  making  splints  (wood  splints,  paste  splints,  metal  splints,  glass 
splints,  plaster  splints,  extension  splints,  articulated  splints). — Complicated  ap- 
pliances for  the  sick-bed. 

§  52.  The  Sick-bed  of  the  Patient. — The  greatest  care  must  be  exer- 
cised as  regards  the  sick-l)ed  of  tlie  surgical  patient.  The  bed  should 
be  SO  arranged  that  tlie  injured  portion  is  easily  accessible  to  the 
physician.  In  general,  it  is  best  to  place  the  head  of  the  bed  towards 
the  window,  to  prevent  the  patient  from  being  blinded  by  the  light. 
It  should  be  as  elastic  as  possible,  and  a  spring  or  horse-hair  mat- 
tress is  far  preferable  to  a  feather  bed.  If  the  patient  must  be  con- 
fined to  bed  for  a  long  time,  it  is  a  very  good  plan  to  have  a  bedstead 
with  contrivances  for  changing  its  shape,  so  that  he  can  readily  be 
brought  into  the  horizontal  or  sitting  position.  A  bedstead  which 
the  patient  can  adjust  to  suit  himself  with  very  little  effort  is  particu- 
larly good.  A  water-tight  rubber  protective  should  be  placed  over  the 
mattress  to  prevent  it  from  getting  wet.  "  Ghristia,"  a  comparatively 
cheap,  durable,  and  sterilisable  preparation,  has  been  recommended  by 
Evens  and  Pistor,  of  Cassel,  as  a  substitute  for  the  ordinary  water-tight 
substances  hitherto  used  (rubber,  oiled  silk,  gutta-percha,  muslin,  etc.). 
The  greatest  care  must  be  used  to  keep  the  bed-linen  perfectly  clean,  so 
that  the  dressings  shall  remain  antiseptic.  If  the  patient  must  lie  for  a 
long  time  upon  his  back,  the  sacral  region  particularly  should  be  pro- 
tected from  all  injurious  pressure  by  means  of  elastic  cushions.  For 
this  purpose  we  use  ring-shaped  air-cushions,  or,  what  is  still  better, 
large  water-cushions  filled  with  warm  water. 

By  means  of  a  swinging  crane  placed  over  the  head  of  the  bed,  or 
a  sling  attached  to  the  foot  of  the  bed,  the  patient  is  enabled  to  raise 
himself.     By  means  of  hoops  joined  together,  or  cradles  (Fig.  163), 

(200; 


§52.] 


THE  SICK-BED   OF   THE   PATIENT. 


201 


Fi(i.  163. — Wire  cradle  for  the  limbs. 


the  bed-clothes  can  be  elevated  from  the  diseased  portion  of  the  body 
npon  which  their  pressure  may  be  uncomfortable,  or  sometimes  even 
painful. 

For  lifting  the  patient  or  some  portion  of  his  body  with  as  little 
disturbance  as  possible,  we  make  use,  when  necessary,  of  special  appli- 
ances called  lifts.  In  the  majority 
of  instances  they  are  not  needed  for 
changing  the  dressings  or  bed- 
clothes, or  for  enabling  the  patient  to 
empty  his  bowels,  and  a  nurse  can 
render  all  the  assistance  required ; 
but  under  many  conditions — for  ex- 
ample, when  the  dressings  on  a  com- 
pound fracture  have  to  be  renewed, 
and  the  part  must  be  held  lifted  up  from  the  bedding  for  some  time 
while  it  is  being  done — we  employ  windlasses,  pulleys,  belts,  fenestrated 
scaffolds,  etc.  The  portable  fenestrated  bed-lift,  which  is  extensible  and 
permits  of  defecation  in  the  recumbent  position,  invented  by  Hamilton 
and  Volkmann  (Fig.  164),  and  Hase's  apparatus  (Illustr.  Monatschrift 
d.  iirzt.  Polytech.,  Heft  6,  1883),  are  very  useful  contrivances.  Volk- 
raann's  bed-lift  is  placed  on  the  bed  over  the  mattress  and  can  be  raised 
by  two  attendants, 
while  the  supports 
at  each  extremity 
can  be  automatically 
adjusted  so  that  the 
apparatus  can  be  re- 
tained at  any  desired 
elevation.  Hase'sap- 
paratus  consists  of 
two  steel  rods  with 
cross-bars  in  the  re- 
gion of  the  shoulders 
and  pelvis,  and  three 
straps  for  raising  the 
head  and  legs ;  from  each  one  of  these  five  parts  a  rope  is  carried  over 
a  roller  on  a  crane  projecting  over  the  bed,  and  the  patient  is  raised  into 
an  elevated  position  by  turning  a  windlass.  For  elevating  any  single 
portion  of  the  body,  such  as  an  extremity,  the  ordinary  suspension  ap- 
paratus will  be  found  sufficient  (Fig.  168).  For  enabling  the  patient 
to  raise  the  upper  portion  of  his  body,  cranes  can  be  devised  with  two 
ropes  and  rings  for  him  to  grasp,  or  straps  can  be  attached  to  the  ceil- 


FiG.  164.- 


Elevated  frame  for  fractures  of  the  vertebne  and  pelvis 
(Hamilton,  Volkmann). 


202  THE  SICK-BED   OF   THE   PATIENT. 

ing  or  to  the  foot  of  the  bed.  The  pelvis  of  the  patient  may  be 
lifted  by  a  trestle  on  which  is  stretched  a  broad  leather  belt  provided 
with  a  fenestrum  for  permitting  evacuation  of  the  bowels.  But  if 
it  is  impracticable  to  disturb  the  position  of  the  patient  at  all,  an 
opening  can  be  provided  in  the  mattress  and  bottom  of  the  bed  for 
enabling  him  to  empty  his  bowels,  or  an  ari-angement  can  be  made 
by  which  the  mattress  may  be  drawn  from  under  him.  The  adjust- 
able bed  of  Hamilton  and  Yolkmann  is  exceedingly  well  adapted  for 
this  purpose. 

§  53.  Sick-bed  Appliances — Splints,  Cushions,  etc. — There  are  numer- 
ous apparatus  and  contrivances  for  obtaining  the  necessary  and  secure 
position  of  a  patient  who  is  confined  to  bed,  or  of  the  particular  part 
of  the  patient  which  has  been  operated  upon. 

1.  Cushions. — The  most  useful  cushions  for  retaining  a  diseased  part 
in  any  required  secure  position  are  made  of  chaff,  chopped  straw,  saw- 
dust, or  sand.  The  cushions  should  be  only  partially  filled,  so  that  the 
contents  may  be  shifted  and  the  cushion  given  any  desired  shape  for 

fitting  the  injured  extremity  and  holding 
it  securely.  Sand  bags  or  cushions  are 
excellent  on  account  of  their  weight,  and 
the  long,  sausage-shaped  bags  are  the  best, 
as  they  can  be  placed  along  the  whole 
Fig.  ig.").— Straw  si^iiiit  for  tern-  length  of  each  sidc  of  an  extremity,  espe- 
cially the  leg.  Chaff  cushions  are  also 
very  good,  as  their  contents  can  be  collected  at  each  end  of  the  bag, 
which  may  then  be  wrapped  around  an  extremity  and  secured  by  a 
bandage,  cloth,  etc.  The  same  eiiect  was  obtained  by  the  old-fashioned 
straw  splint  (Fig.  165),  which  can  be  made  very  simply  by  wrapping 
the  two  ends  of  a  good-sized  strip  of  cloth  around  bundles  of  straw  or 
some  similar  material ;  the  extremity  is  placed  between  two  bundles, 
where  it  can  be  secured  with  a  bandage. 

Tightly  stuffed  cushions  of  horse-hair  or  seaweed,  the  shape  of 
which  cannot  be  altered,  are  also  used.  In  this  class  are  Stromeyer's 
triangular  axillary  cushion  with  its  rounded  corners,  and  Middledorff's 
wedge  cushion  for  fracture  of  the  humerus.  Large,  wedge-shaped 
pads  have  been  invented  for  the  lower  extremity  also,  having  two 
plane  surfaces  inclined  at  an  angle  to  each  other. 

2.  The  Single  and  Double  Inclined  Plane. — If  it  is  desirable  to  ele- 
vate the  peripheral  end  of  an  extremity  either  for  inflammatory  swell- 
ing, simple  congestion,  or  for  some  injury  or  after  an  operation,  it  can 
be  accomplished  very  readily  by  placing  beneath  the  extremity  chaff 
cushions  arranged  so  as  to  form  a  simple  inclined  plane.     The  same  re- 


§r,;{,i 


SICK-BED   APPLIANCES-SPLINTS,   CUSHIONS,   ETC. 


203 


riaiiuin  iuclilialuiu  duplex. 


suit  can  1)0  attained  by  j)laciii<^  under  the  leg  an  oixlinary  board  w  itli 
its  distal  end  raised,  and  i)articularly  by  usin<^  Fetit's  box  sj)lint  (Fi<r. 
167).     The  double   inclined    plane  is  used   chiefly   for  the   lower  ex- 
tremity,    A  lar<;e,  wedge- 
sha()ed  cushion  will  answer 
the  ])urpose,  or  a  couple  of 
boards  joined  by  a  hinge 
and  fastened  with  strings    fill 
so  as  to  maintain  any  de-  (~LLl^ 
sired    angle.       Esmarch's 
planum  inclinatum  duplex 
fitted  witli  lateral  retention  pegs  is  exceedingly  useful  (Fig.  166). 

3.  Splints. — Leg  splints  are  chiefly  employed  for  fractures  below 
the  knee,  and  they  may  be  used  with  advantage  in  all  injuries  of  the 
leg.  Petit's  splint  is  a  thoroughly  good  one  (Fig.  167).  Ileister  in- 
troduced it  in  Germany,  and  consequently  it  has  been  called  by  the  lat- 
ter's  name.  By  means  of  the  wooden  props  attached  to  its  bottom  the 
splint  can  be  raised  or  lowered,  producing  a  greater  or  less  amount  of 
flexion  at  the  knee,  as  the  board  under  the  thigh  moves  with  the  splint, 
to  which  it  is  attached  by  a  hinge  joint.  This  splint  can  be  made  into 
either  a  planum  inclinatum  simplex  or  duplex.  The  side-  and  foot- 
pieces  can  also  be  turned 

down,  rendering  frequent 
inspection  of  the  extremity 
possible.  The  position  of 
the  extremity  is  represented 
in  Fig.  167,  with  the  pads 
which  surround  it.  A  long 
chaff  cushion  is  laid  on  each 
side  of  the  leg,  and  a  greater 
or  less  amount  of  cotton  or 
jute  is  stuffed  into  the  in- 
equalities to  prevent  any 
displacement  of  the  fragments  in  the  broken  leg.  Several  turns  of  a 
bandage,  or  folded  strips  of  cloth,  are  taken  around  the  foot  and  foot- 
piece  and  around  the  leg  and  body  of  the  splint  to  secure  the  limb  in 
position. 

4.  Suspension.— All  the  old-fashioned  suspension  appliances  for  hold- 
ing the  extremity  in  proper  position  are  at  present  entirely  superfluous, 
as  we  now  combine  all  the  various  retention  and  extension  dressings 
with  suspension.  Eetention  dressings,  particularly  plaster  bandages, 
will  be  again  referred  to  later  on.     As  will  be  seen,  we  now  use,  in 


Fig.  107. — Petit's  box-splint  for  the  leg. 


204 


THE  SICK-BED   OP   THE   PATIENT. 


combination  with  suspension,  retention  dressings,  which  harden  after 
their  application,  especially  plaster-of-Paris  bandages,  with  or  without 
inserting  splints  or  telegraph  wire  (Figs.  168,  169,  181,  182,  186,  196, 

198,  199,  207,  208,  209). 
Amongst  the  various  kinds  of 
suspension  splints  in  use  those 
chiefly  worthy  of  mention  are 
Volkmann's  (Fig.  177),  Es- 
march's  wood  or  telegraph  wire 
splint  for  the  upper  and  lower 
extremities  (Figs.  169,  182), 
Smith's  anterior  wire  splint  (Fig. 
186),  Beely's  gypsum-hemp  splint 
(Fig.  200),  Volkmann's  wooden 
dorsal  splint  (Fig.  181),  and  Es- 
march's  stirrup  splint  for  the  leg 
and  foot,  which  consists  of  two 
splints,  one  for  the  sole  of  the 
foot,  the  other  for  the  leg,  the 
two  being  joined  by  a  dorsal 
arch  or  bow.  The  special  splints 
adapted  to  curvature  of  the  spine 
will  be  described  in  the  text-book 
on  Special  Surgery.  Rauchfuss's 
suspension  appliance  is  represented  in  Fig.  218. 

The  simplest  way  of  suspending  the  lower  extremity  is  illustrated 
in  Fig.  196,  where  the  limb  is  encased  in  a  fenestrated  plaster  splint 
and  hung  from  a  wood  or  iron  frame  by  a  couple  of  strips  of  bandage. 
The  point  of  support  can  also  be  arranged  in  the  form  of  a  gallows 
having  a  horizontal  stick  of  wood  attached  at  right  angles  to  an  up- 
right (Figs.  207,  208).  I  use  an  adjustable  iron  frame  with  rollers, 
as  in  Fig.  168.  The  cross-bar  can  be  raised  or  lowered  to  any  conven- 
ient height  by  means  of  the  handle  A.  The  rope  for  exerting  the  trac- 
tion with  the  weight  Gr  runs  over  wheels,  which  can  be  moved  to  one 
side  or  the  other  and  readily  retained  at  any  point  by  the  notches  in 
the  cross-bar.  Iron  frames  which  can  be  fastened  to  the  bed  are  very 
useful. 

5.  Wire  Splints.  Wire  Gutters,  Stockings,  and  Cases. — Wire  gutter 
splints  (Figs.  170,  172)  are  as  simple  as  they  are  comfortable,  and  have 
supplanted  to  a  large  extent  the  contrivances  just  described.  Wire 
gutters  are  usually  made  of  wide-meshed  wire  gauze,  padded  with  a 
thin  layer  of  horse-hair  or  small  cushions  of  cotton,  jute,  etc.    They  are 


Fig.  168. — The  author's  suspension  apparatus. 


§53.] 


SICK-BED    APPLIANCES— SPLINTS,   CUSHIONS,    ETC. 


205 


straight,  or  bent  at  an  angle,  and  of  various  lengths  and  sizes.  As  they 
are  tlexible  they  can  be  made  to  fit  the  limb  more  or  less  a(!curately  by 
means  of  straps.     Koser's  contrivance  is  very  useful.     It  consists  of  a 


Fui.    17<i. — Wire    ^f utter    for  the 
upper  extremity. 


Fio.  109 — Suspiiil<  1  14  1  .  t  I  11  niit\  ,  inter- 
rupted plaster  dressiug-  with  .splints  luul  tele- 
grapli  wire. 


Fig.    171. — Wire   gutter    for  the 
lower  e.xtreniity. 


Fig.  172.- 


-Bonnet'.s  wire  stocking  for  both  lower  extremities 
and  the  pelvis. 


wire  gutter  for  the  entire  lower  extremity,  and  is  made  in  two  or  three 
different  parts,  which  can  be  telescoped  together  to  any  desired  extent 
and  fixed  in  the  proper  position  with  strings.  For  immobilising  both 
loMer  extremities,  together  with  the  pelvis,  for  example,  in  fractures  of 
the  latter.  Bonnet's  wire 
stockings  are  widely 
used  (Fig.  172).  Bon- 
net has  also  invented  an 
excellent  wire  frame  or 
case  for  enclosing  the 
whole  body  in  fractures 
of  the  vertebra. 

6.  Splints  and  Splint  Bandages.— Splints  are  generally  employed  in 
the  treatment  of  fractures  and  in  making  dressings  which  harden  after 
their  application,  as  well  as  ordinary  antiseptic  dressings. 

Splints  are  made  in  an  immense  variety  of  shapes,  either  resembling 
more  or  less  deep  gutters,  or  only  slightly  concave  or  entirely  flat; 
they  may  be  straight,  or  bent  at  a  right,  acute,  or  obtuse  angle.  The 
])articular  kind  of  splint  required  for  this  or  that  portion  of  the  body 
will  be  dealt  with  in  the  Special  Surgery,  and  only  a  general  review  will 
be  given  here.  Splints  are  made  of  wood  pulp,  metal,  silica,  felt, 
plaster,  etc. 

Wooden  Splints.— The  stiff,  unyielding  wooden  splints  are  usually 
made  from  the  coarse  heart  wood  of  the  tree ;  they  are  flat  or  slightly 
concave,  or  fashioned  to  fit  the  contour  of  a  particular  portion  of  the 
body,  and  they  may  be  straight  or  bent  at  an  angle.  Fenestrse  are  usu- 
ally cut  in  them  to  correspond  to  any  projecting  portions  of  the  body. 


206 


THE  SICK-BED   OP   THE   PATIENT. 


such  as  the  internal  condyle  of  the  humerus  at  the  elbow,  or  the  malleoli 
at  the  ankle,  and  thus  the  skin  over  these  points  is  preserved  from  an 


Fig.  173. — Splints  for  the  arm  and  Land 


undue  amount  of  pressure,  which  might  cause  it  to  become  gangrenous. 
In  Fig.  173  are  represented  various  kinds  of  splints  for  the  upper  ex- 
tremity ;  they  are  straight,  or  bent  at  an  acute  or  ol;>tuse  angle,  and  made 


Fio.  174. — Esrnarcli's  splint  for  the  arm  in 
case  of  resection  of  the  elliow. 


Fio.  173.  — Volkmann's  supination  splint. 


of  wood  or  papier-mache.  The  splints  {c  iof)  are  padded  with  cotton^ 
jute,  or  tow,  and  then  covered  with  ruljber  tissue,  the  ends  of  which 
are  stuck  to  the  back  of  the  splint  with  chloroform.  These  splints  are 
used  almost  exclusively  for  inflammation,  injuries,  and  fractures  of  the 
fingers,  hand,  and  forearm.  The  splint  d  is  somewhat  modified  from 
Nelaton's  pistol  splint  for  fracture  of  the  radius. 

Wooden  arm  splints  for  the  entire  upper  extremity  can  be  made 
like  the  models  represented  in  Fig.  173,  e  or  f.  Esmarch's  arm  splints 
(Fig.  174)  are  also  very  useful,  for  example,  after  resection  of  the  elbow- 
joint  ;  Volkmann's  supination  splint  is  likewise  good,  and  enaV)les  the 
arm  to  be  immobilised  in  a  position  between  pronation  and  supination 
(Fig.  175). 

Esmarch's  double  splint  (Fig.  176)  is  exceedingly  good  for  a  resected 


§53.] 


SICK-BED   APPLIANCES— SPLINTS,  CUSHIONS,   ETC. 


207 


elbow-joint.  It  consists  of  two  parts  upon  whicli  the  arm  rests,  the 
upper  i)ortion  being  joined  to  the  lower  by  a  steel  bow  (Fig.  176,  h). 
If  it  is  desirable  to  place 
the  forearm  and  hand  in 
a  vertical  position,  in  cases 
of  acute  inflammation,  in 
order  to  lessen  the  con-' 
gestion,  Volkmann's  sus- 
pension splint  is  very  use- 
ful (Fig.  177) ;  the  ring 
at  the  extremity  of  the 
splint  is  employed  for 
suspending  it  in  the  ver- 
tical position  ;  but  an  ar- 
rangement of  cushions 
and  bandages  will  ordi- 
narily be  found  sufficient 
for  securing  the  forearm 
in  position. 

The  two  excellent 
splints  of  Esmarch  and 
Lister  for  resection  of  the 
wrist  are  represented  in 
Fig.  178,  a,  h,  and  Fig. 
179.  Esmarch's  bow 
splint  is  easily  made  from 
a  piece  of  wood  or  sheet 
iron. 

Amongst  the  great 
number  of  wooden  splints 
for  the  lower  extremity, 
mention  should  be  made 
particularly  of  AVatson's 
splint  (Fig.  ISO)  for  the 
posterior  surface  of  the 
leg,  with  a  notch  for  the 
heel,  and  of  Bell's  splint 
for  the  thigh  or  leg,  made 

of  two  strips  of  wood  buckled  together  by  a  strap.    Yolkmann's  wooden 
dorsal  splint  is  another  good  one  (Fig.  181). 

Esmarch's  wooden  splint  for  resection  of  the  ankle-joint  is  repre- 
sented in  Fig.  182;  it  is  applied  to  the  posterior  surface  of  the  leg. 


Fig.  1T6.— Esmarch's  double  splint  for  resections  of  the 
elbow. 


Fig.  177.— Volkmann's  suspension  splint. 


208 


THE  SICK-BED   OF   THE   PATIENT. 


which  is  tlien  wrapped  in  gypsum  bandages  and  suspended  from  hooks 
made  of  telegraph  wire. 


Fig.   178. — Esmarch's   interrupted  splint  for 
resections  of  the  wrist. 


Fia.   181. — Volkmann's    dorsal    splint    (for 
suspension). 


Fig.  179. — Listers  splint  for  resections  of  the 
wrist. 


Fig.  180. — Watson's  splint  for  the  lower  ex- 
tremity. 


Fig.  182. — Esmarcli's  wooden  splint  for  re- 
sections of  the  ankle. 


Pliable  Wooden  Splints. — In  additio!i  to  these  stiii  wooden  sphnts 
there  have  been  recommended  sphnts  made  of  wood  which  is  capable 
of  bending,  but  they  have  not  been  received  with  as  much  favour  as 
they  deserve.  They  are  always  well  suited  for  making  an  impromptu 
dressing,  especially  in  transporting  patients  to  the  hospital.  Even  in 
ancient  times,  according  to  the  assertion  of  E.  Fischer,  splints  were 

manufactured  from  wood  which 
could  be  bent  into  any  desired  shape. 
For  this  purpose  there  were  used  the 
stem  of  the  Spanish  broom,  strips  of 
wood  cut  very  thin,  pieces  of  veneer- 
ing, green  twigs,  palmetto  leaves,  and 
the  bark  of  trees.  According  to 
the  same  authority  the  Turks  use 
moulded  wooden  splints  made  of  the 
fibrous  portions  of  palmetto  leaves  sewed  to  thin  leather,  thus  obtaining 
a  material  which  can  be  applied  to  an  injured  limb  either  circularly  or 
in  the  form  of  a  gutter.  Martini  and  Gpoch  glue  narrow,  thin  strips  of 
wood  taken  from  the  linden  tree  close  together  upon  soft  leather,  and 


Fig.  183.- 


-Esmarcli's  materials  for  making 

splints. 


J^53.]  SICK-UKI)    Al'l'l.lANCKS-.Sl'LINTS.   CL'SIIIONS,    ETC.  20'J 

ill  this  way  a  splint  can  be  made  wliicli  is  an  excollcTit  temporary  dress- 
ing for  a  fracture,  particularly  of  the  lower  extremity.  Esmarcirs  splint 
material,  which  can  be  cut  into  any  required  size,  is  very  similar  to  this 
(Fig.  183).  It  consists  of  strips  of  wood  three  centimetres  wide  and 
one  and  a  half  centimetre  thick,  which  are  glued  between  two  layers 
of  cotton  cloth.  Ilerzenstein  advises  that  splints  be  made  after  the 
fashion  of  the  ordinary  trellis  work  used  for  supporting  vines.  Reeds, 
willow  withes,  and  straw  made  into  mats  have  also  been  recommended 
as  splints.  Thin,  pliable  strips  of  wood  about  three  to  four  centi- 
metres wide  make  a  very  good  material  for  splints  when  combined 
with  plaster  bandages,  and  are  also  very  useful  for  immobilising  a  joint 
after  an  antiseptic  dressing  has  been  apjilied. 

"Wood  Dressings. — Waltuch  recommends  wood  dressings  made  of  shav- 
ings, 4'5  centimetres  wide  and  0  5  to  1  millimetre  thick,  and  any  desired 
length,  which  are  prepared  by  planing  pine  planks  in  a  particular  way.  The 
wood  shavings  roll  up  spontaneously  like  a  bandage,  are  more  easily-  handled 
than  thin  board  splints,  and  much  cheaper  than  the  latter.  This  wood  dress- 
ing, consisting  of  shavings  bound  together  with  glue,  is  suitable  for  corsets, 
for  encasing  a  limb,  etc.     (Wien.  kiln.  Wochensch.,  1888,  No.  10.) 

Papier-mache  Splints. — Splints  made  of  stout  papier-mache,  about 
three  millimetres  thick,  are  very  frequently  employed  for  immobilis- 
ing purposes.  These  splints  are  usually  made  with  flat  edges,  which 
may  be  bent  into  any  required  shape,  or  else  flat  pieces  are  used  of 
varying  widths.  After  dipping  this  material  in  warm  water  just  be- 
fore it  is  to  be  used,  it  becomes  soft,  and  can  be  readily  made  to  fit  any 
part  of  the  body  when  fastened  on  with  a  bandage.  The  small  papier- 
mache  splints  are  chiefly  used  for  strengthening  dressings  in  which 
starch  is  employed. 

Metal  Splints. — Metal  splints  are  generally  made  of  iron,  sheet  iron, 
tin.  zinc,  telegraph  wire,  wire  gauze,  etc.,  and  may  be  stiff  and  un- 
yielding or  capable  of  being  bent 
into  any  shape.  Yolkmann's 
sheet-iron  splint  (Fig.  184)  is  ex- 
ceedingly good,  and  in  very  gen- 
eral use  for  the  lower  extremity. 
It  is  a  good  plan  to  make  this  of 

two  parts— an  upper  and  lower—  ^'«-  ^^^•"^''''''"^'"efextreuliir'  '^^'°'  ^"'  '^"^ 
for   lengthening  and  shortening 

the  splint  any  necessary  amount  (Miigge).  Metal  splints  which  are  cap- 
able of  being  bent  into  any  shape  are  best  made  of  telegraph  wire,  tin, 
zinc,  or  galvanised  iron.  Flat  splints,  made  of  thin  tin  plate,  have  been 
recommended  by  Solomon  and  introduced  in  the  Danish  army;  they 
15 


210 


THE   SICK-BED   OP   THE   PATIENT. 


are  thirty-five  centimetres  long  and  ten  centimetres  wide,  having  at  one 
end  two  small,  three-pronged  projections,  which  are  hook-shaped  and 
notched,  and  at  the  other  two  clefts,  into  which  the  projections  are  in- 
serted and  secured,  thus  rendering  it  possible  to  make  a  splint  of  any 
desired  length.  Thin  galvanised  iron  which  is  capable  of  being  cut 
with  shears  has  been  recommended,  especially  by  Schon  and  Weiss- 
bach,  as  a  material  suitable  for  splints.     Schon  gives  directions  for 


f- 


A 


_72 


Fig.  185. — Pattern  for  cutting  out  a  gutter  for  the  arm  or  leg  (Schon). 

making  excellent  splints  in  a  very  short  time  from  this  substance,  and 
hinge  joints,  fenestrse.  and  interrupted  spaces  can  be  inserted.  In  Fig. 
185  is  represented  a  simple  way  of  making  a  gutter  splint  for  the  arm 
and  leg. 

The  gutter  splint  for  the  arm  (Fig.  185,  a)  is  made  by  cutting  out  a  splint 
of  the  desired  size  and  bending  it  on  its  long  axis  so  as  to  form  a  shallow 
groove,  and  then  transversely  so  as  to  make  an  obtuse  or  right  angle.  Strings 
are  passed  through  the  punctures  at  a  a,  and  tied  to  maintain  the  splint  at 
the  proper  angle.  The  gutter  splint  for  the  leg  is  cut  from  galvanised  sheet 
iron,  as  represented  in  Fig.  185,  b  ;  it  is  then  bent  on  its  long  axis  into  a  half 
circle,  and  the  foot-piece  is  formed  by  bringing  the  lateral  parts  a  a  around 
behind  the  middle  part,  and  retaining  them  in  this  position  by  strings  or 
wires. 

Wire  Splints,  made  from  properly  bent  telegraph  wire  or  from  wire 
netting,  have  recently  come  into  considerable  favour.  Telegraph  wire  is 
chiefly  used  at  present  for  making  suspension  s]ilints,  and  in  the  prepa- 
ration of  the  interrupted  plaster 
splint  (Figs.  197-199).  One  of  the 
best  known  kinds  of  wire  splint  is 
Smith's  (Fig.  186),  wdiich  is  espe- 
cially well  suited  for  the  treatment 
of  compound  fractures  of  the  lower 
extremity.  It  is  made  of  two  nearly 
])arallel  bars  joined  at  their  extremities  and  in  the  intervening  space  by 
from  two  to  four  movable  wire  arches  or  hoops,  to  which  are  attached 
the  ropes  for  suspending  the  splint.  At  three  places — namely,  over  the 
ankle,  knee,  and  hip  joints — it  is  slightly  bent,  and  is  then  applied  to 


Fig.  186. — Smith's  anterior  wire  splint. 


§53.] 


SICK-BED  APPLIANCES— SPLINTS,  CUSUIONS,   ETC. 


211 


the  aiiterior  t^urfacc  of  the  liinb,  to  which  it  is?  secured  generally  by  a 
plaster  banciage. 


f\J7|  / 


Fio.  187. — Esniarch's  splint  lor  the  arm, 
inade  out  of  tek'j,'raph  wire. 


Fio.   1 


-E.sinarch's  wire  sieve   splint  with 
strings. 


mu 


Esinarch  has  constructed  a  splint  (Fig.  187)  of  telegraph  wire  for 
the  upper  extremity,  which  approaches  the  character  of  the  splints 
made  of  wire  gauze  gutters  for  the 
upper  and  lower  extremities  (Figs. 
170, 171).  Woven  wire  is  also  used 
for  making  splints  which  can  be 
bent  into  different  shapes.  Esmarch 
has  recommended  the  use  of  long 
strips  of  wire  lattice  for  splints  (Fig. 
188),  and  from  this  material  it  is 
very  easy  to  make  a  splint  similar 
to  Bonnet's  stocking  (Fig.  172). 
Cramer's  lattice-work  splint,  made 
of  iron  wire  tinned  over,  is  exceed- 
ingly good  both  for  ordinary  practice 
and  for  army  surgery.  These  splints 
can  be  bent  into  any  shape,  and  can 
be  made  to  fit  over  any  dressing  or 
any  part  of  the  body  (Fig.  189),  and 
they  can  be  lengthened  by  fastening 
one  or  more  together.  By  taking 
out  some  of  the  cross-pieces  and 
bending  the  lateral  bars  the  splint 
can  be  made  interrupted,  or  can  be 
bent  at  any  angle  (Fig.  189,  6?,  e). 
Xeuber  has  recommended  splints 
made  of  glass  (Figs.  190,  191),  as 
particularly  good  for  cases  where  an 
antiseptic  dressing  is  left  in  place 
for  a  considerable  time.  They  are  transparent,  and  permit  all  parts  of 
the  dressing  to  be  inspected  without  disturbing  the  limb.    Glass  splints 


Fig.  189. 


Pliable  splints  made  of  iron  wire 
tinned  over  ( Cramer). 


212 


THE   SICK-BED   OF   THE    PATIENT. 


are  comparatively  cheap,  very  clean,  and  not  so  easily  broken  as  one 
might  imagine,  Gluck  has  had  splints  made  of  glass,  porcelain,  and 
earthenware. 

Plastic  Splints. — ]\Ioulded  splints  are  prepared  by  wetting  or  heating 
the  material  of  which   thev  consist,  and  when  it  has  become  soft  and 


Fig.  r,'i.'. —  NtU'i-r's  frlas?  splint  for  the 
uppt- r  extremity. 


Fie.  191. — Neuber's  crlai^s  splint  for  the 
lower  extreniitv. 


plastic  it  is  made  to  fit  snngly  over  some  particular  portion  of  tlie 
body  by  the  aid  of  a  roller  bandage.  After  the  material  becomes  dry 
or  cold,  whichever  the  case  may  be,  a  hard,  unyielding  splint  results 
which  fits  very  closely.  Such  splints  may  be  made  in  the  shape  of 
strips  of  from  two  to  four  fingerbreadths  in  width,  or  in  the  shape  of  a 
gutter  which  may  surround  a  half  or  the  entire  circumference  of  a  limb. 

Papier-mache.— In  the  preparation  of  these  splints  ordinary  papier- 
mache  can  be  used,  though  it  only  possesses  a  moderate  amount  of  firm- 
ness when  dry.  The  prepared  papier-mache  of  P.  Bruns  is  better,  and 
consists  of  ordinary  papier-mache  which  has  been  impregnated  with 
some  hardening  substance,  generally  shellac.  When  this  preparation  is 
warmed  in  a  hot  oven,  or  wet  in  boiling  water,  it  becomes  soft,  and 
capable  of  being  moulded  into  any  shape  in  a  very  few  minutes,  and 
sub.^equently  1)ecomes  as  hard  as  wood  in  from  five  to  ten  minutes. 

Plastic  Felt. — Pliable  felt  can  be  used  in  a  similar  manner,  and  P. 
Bruns  describes  its  preparation  as  follows :  A  sheet  of  ordinary  felt, 
from  five  to  eight  millimetres  thick,  is  soaked  in  a  solution  consisting 
of  one  part  shellac  to  one  and  a  half  parts  of  alcohol  until  it  has  be- 
come completely  saturated,  or  until  the  felt  will  absorb  no  more  of  the 
solution.  (It  takes  up  about  four  times  its  own  weight.)  It  is  then 
allowed  to  dry,  and  from  this  material  excellent  splints  can  be  made  in 
the  shape  of  flat  strips,  or  gutters,  or  cases.  After  cutting  the  piece  of 
])lastic  felt  into  the  proper  shape,  it  is  dipped  into  v.ater  which  is 
almost  boiling,  or  stroked  with  a  hot  flat-iron  or  laid  on  a  hot  stove-lid, 
which  causes  it  to  become  as  soft  as  any  ordinary  unimpregnated  felt. 
The  softened  felt  is  then  applied  with  a  roller  bandage  to  the  limb, 
which  has  been  pi-eviously  covered  with  a  bandage  or  with  cotton,  and 
in  a  short  time  this  splint  becomes  as  hard  as  a  board.  F.  Schwarz  has 
used  moulded  felt  in  Billroth's  clinic,  as  a  substitute  for  more  expensive 


§53.]  SI("K-HFJ)   APPLIANCES— SPLINTS,   CUSHIONS,   ETC.  21^ 

and  eoinplieated  contrivances,  with  the  very  best  results  (AVien.  med. 
WoclR'ii.-ch.,  186(),  Xo.  37.) 

Gutta-percha. — Gutta-percha  can  be  used  'n  a  similar  manner  for 
making  straight,  gutter,  or  case  splints.  Gutta-percha,  or  the  dried  sap 
of  an  East  Indian  tree  {I-Honandra  gutta,  Sapotacee),  was  introduced  in 
Europe  in  1843,  and  was  first  used  for  treating  fractures  in  England  in 
1840,  though  it  had  been  employed  for  this  purpose  in  Borneo  a  long 
time  previously.  AVlien  gutta-percha  is  warmed  in  hot  water  it  becomes 
soft  and  capable  of  receiving  any  shape,  and  then  hai-dens  when  it  cools 
off,  in  about  fifteen  minutes.  For  making  straight,  gutter,  or  case 
splints  of  gutta-percha,  sheets  of  this  material  are  cut  into  the  proper 
form  and  softened  by  immersion  in  water  at  a  temperature  of  75°  to 
85°  C.  The  splint  is  then  allowed  to  cool  o£E  slightly,  and  after  being 
modelled  into  the  shape  required  to  fit  the  particular  extremity,  which 
has  been  previously  encased  in  a  flannel  bandage,  it  is  kept  in  place  by 
a  wet  roller  bandage.  By  gluing  together  the  edges  of  two  gutters  a 
circular  splint  may  be  made.  Gutta-percha  is  not  affected  by  water, 
blood,  pus,  or  urine,  but  it  is  expensive,  and  on  this  account  has  not 
been  very  generally  used. 

Caoutchouc  Splints. — The  black,  stiff  splints  made  of  caoutchouc  are 
also  very  good,  and  can  be  made  to  assume  almost  any  form  by  warm- 
inff  them  in  hot  water. 

Leather. — Ordinary  leather  is  an  excellent  material  for  making 
straight  or  case  splints  ;  it  should  be  soaked  in  water  and  applied  to  the 
limb  with  a  roller  bandage  while  in  a  wet  condition,  when  it  is  capable 
of  being  moulded. 

Paraffin. — Paraffin  has  been  recommended  for  splints,  but  it  is 
hardly  firm  enough,  and  is  very  apt  to  cause  an  eczema.  The  plaster 
splint  is  referred  to  in  g  54  (Plaster  Dressings). 

The  Author's  Plastic  Splint. — I  have  had  made  an  excellent  plastic 
material  for  the  manufacture  of  splints ;  it  is  prepared  from  the  fibres 
of  an  African  plant,  and  can  be  had  of  the  firm  of  F.  Flinch,  in  Leip- 
sic.  A  piece  of  this  material  is  cut  of  the  proper  shape  and  dipped 
in  hot  or  boilins  water,  and  is  thus  made  so  soft  that  it  can  be  moulded 
into  any  form.     After  a  short  time  this  splint  becomes  very  hard. 

Cellulose  Splints.— R.  de  Fischer  has  advised  the  use  of  a  hardening  mate- 
rial for  splints  made  of  eelhdose.  Thick,  flat  plates  of  cellulose  are  manu- 
factured for  this  purpose  having  the  outline  of  the  difPerent  limbs,  and 
strengthened  on  one  side  with  water  glass.  This  side  of  the  splint  is  then, 
before  use,  painted  over  with  nearly  boiling  water,  which  causes  the  material 
to  become  immediately  soft  and  pliable.  The  splint  is  applied  wet  side  out. 
and  fastened  in  position  with  gauze  bandages  which  have  been  saturated  with 


21i 


THE   SICK  BED   OF   THE  PATIENT. 


cold  water.  These  splints  can  be  strengthened  by  impregnating  tbein  with 
water  glass  on  both  sides.  They  are  said  to  possess  the  advantage  of  simplic- 
ity, rapidity  in  hardening,  lightness  and  durability,  and,  furthermore,  cost 
very  little.    They  are  manufactured  by  the  apothecary  in  Triest,  Karl  Zanetti. 

Extension  Splints. — Before  the  introduction  of  extension  bj  weiij:ht, 
extension  splints  were  employed^  and  they  will  be  referred  to  in  their 
proper  place. 

Articulated  Splints. — Jointed  splints  are  those  consisting  of  two  or 
more  ordinary  splints  united  b}'  a  joint  or  some  material  capable  of 

bending,  such  as  caoutchouc, 
cloth,  leather,  etc.  A  jointed 
splint  can  be  fastened  at  any 
desired  angle,  or  can  be  left 
movable,  permitting  free 
motion  in  the  extremity  to 
which  it  is  applied. 

There  is  a  great  variety 
of  these  articulated  splints, 
the  best  one  probably  being 
Heine's  (Fig.  192),  though 
Bidder,  Liieke,  and  others  have  constructed  very  excellent  splints. 
These  articulated  splints  can  be  used  for  exerting  a  gradual  extension 
on  contracted  joints,  for  overcoming  contractures  of  the  muscles  and 


Fig.  192. 


-Heine's  disjointable  articulated  splint  for  the 
upper  extremity. 


Fig.  193. — Adjustable  clamp  apparatus. 


Fig.  194. — Clamp  apparatus  pro- 
vided with  a  joint. 


soft  parts,  and  for  the  after-treatment  of  resected  joints  as  a  supporting 
apparatus. 


t5  5:}.]  SICK-BKD   APPLIANCES— SPLINTS,   CUSHIONS,   ETC.  215 

Stillmann  liiis  also  rocoTinneiided  an  excellent  adjustable  brace, 
which  permits  njotioii  in  the  joint  to  which  it  is  a})plied,  and  whicli 
can  be  readily  included  in  a  plaster  dressing  (Figs.  193,  194).  Be- 
sides all  these  appliances  which  have  just  been  described,  a  great  num- 
ber of  complicated  apparatus  for  securing  parts  in  their  proper  position 
have  been  devised  and  recommended,  but  the  majority  of  them  can  be 
easily  dispensed  with.  Later  on  we  shall  become  acquainted  with  sev- 
eral simple  contrivances  in  the  way  of  dressings  and  braces  for  treating 
particular  diseases  and  injuries,  but  it  has  been  intended  at  present  to 
give  only  a  brief  review  of  the  most  useful  appliances  which  are  at  our 
disposal. 

Improvised  Dressings  of  the  Battle-field. — In  times  of  war  it  may 
become  necessary  to  improvise  dressings  and  splints  out  of  whatever 
materials  may  be  at  hand.  J.  Port  has  written  a  book  on  this  subject 
(Stuttgart,  Ferd.  Enke,  1892),  in  which  are  a  number  of  illustrations  and 
desci-iptions  of  materials  which  can  be  used  as  surgical  dressings. 

Apparatus  for  Home  Gymnastics. — Brief  mention  should  be  made  in 
this  place  of  the  different  kinds  of  apparatus  used  for  gymnastic  pur- 
poses which  should  always  be  found  in  every  hospital.  It  would  take 
too  much  space  to  describe  them  except  in  a  very  general  way.  L.  Ewer 
has  lately  recommended  a  house-boat  which  is  a  very  good  substitute  for 
rowing  on  the  water.  It  forms  an  excellent  addition  to  the  number  of 
contrivances  for  home  gymnastics  (see  lllustr.  Monatsch.  fiir  artz.  Poly- 
tech.,  Feb.,  1889).  The  machines  invented  by  Zander,  of  Stockholm, 
afford  many  kinds  of  gymnastic  exercise  which  are  exceedingly  useful 
in  some  cases,  and  their  place  cannot  be  supplied  by  either  massage  or 
passive  motion. 


CHAPTER  V. 

TIIK  APPLICATION    OF  IMMOBILISING   DRESSINGS   MADE   OF  MATERIALS  WHICH 

GRADUALLY  HARDEN. 

Tlie  application  of  extension   dressings. — Plaster  dressinjis. — Dressings   of   tripolith, 
starch  paste,  gutta-perciia,  and  felt. — The  methods  of  a[)plying  extension  dressings. 

§  54.  Immobilisation  Dressings  of  Hardening  Substances. — Dressings 
for  producing  innnobilisatioii  are  used  for  fractures,  iniianimations  in 
joints,  and  after  many  operations — for  example,  in  the  after-treatment 
of  resections  and  osteotomies,  etc. ;  they  serve  the  pur})ose  of  prevent- 
ing movement  in  the  part  of  the  body  under  treatment.  Even  in 
ancient  times  attempts  were  made  to  form  immobilisation  dressings 
from  substances  which  would  subsequently  harden,  but  the  methods 
were  imperfect.  To  Larrey,  the  distinguished  army  surgeon  of  Ka- 
poleon  I.,  belongs  the  honour  of  having  generally  introduced  those 
immobilising  dressings  which  were  applied  in  the  soft  state  and  then 
allowed  to  harden.  Larrey  soaked  the  dressings  for  twenty-four  to 
thirty-six  hours  in  a  mixture  made  of  albumen,  liquor  plumbi  subace- 
tatis,  and  spirits  of  camphor.  This  somewhat  tedious  procedure  was 
supplanted  by  the  starch  dressing  invented  by  Seutin  in  1834.  As 
the  starch  dressing  took  a  long  time  to  harden,  attention  was  directed 
to  some  more  raj^idly  hardening  material,  and  gypsum  was  taken  up,  a 
substance  which  had  been  employed  by  the  Arabian  physicians.  The 
honour  of  introducing  the  gypsum  dressing  and  the  methods  of  apply- 
ing it  is  due  to  the  two  Dutch  physicians,  Mathysen  and  Van  der  Loo. 
Numbers  of  other  hardening  substances,  such  as  water  glass,  tripolith, 
etc.,  have  also  been  used  in  the  same  way. 

The  Gypsum  Dressing. — Amongst  all  the  materials  employed  for  mak- 
ing an  immobilising  dressing  there  is  none  better  than  gypsum,  pos- 
sessing, as  it  does,  the  power  of  rapidly  becoming  hard.  Gypsum,  or 
plaster  of  Paris,  is  hydrated  sulphate  of  calcium  (CaSO^ -j- 2HjO). 
The  gypsum  used  in  dressings  is  burned  or  dehydrated,  and  after  mix- 
ing it  with  water  it  hardens  in  a  few  minutes  to  a  solid  mass,  forming 
with  water  a  firm  chemical  combination.     The  plaster  dressing  can  be 

(216) 


^54.]  IMMOBILISATION    DRESSINGS   OF   HARDENING   SUBSTANCES.  217 

applied  in  many  different  ways,  the  best  being  in  the  form  of  phister 
bandages.  For  this  purpose  bandages,  preferably  of  gauze,  are  im- 
pregnated with  dry  gypsum  powder  by  rolling  them  in  the  latter  and 
working  it  into  the  meshes  of  the  gauze.  Soft  mull  bandages  can  aho 
be  treated  in  the  same  way.  The  application  of  the  gypsum  dressing 
is  begun  by  smoothly  enveloping  the  particular  portion  of  the  body 
with  a  soft  mull  or  Hannel  bandage,  or  with  a  thin  layer  of  cotton,  over 
which  is  placed  a  soft  mull  bandage.  In  cases  where  it  is  necessary, 
the  extremity  may  first  be  greased  with  oil,  lard,  or  vaseline,  to  prevent 
the  plaster  from  sticking  to  the  hairs ;  bony  projections  should  be  cov- 
ered with  a  little  cotton,  to  avoid  pressure  at  these  points  ;  and,  above  all, 
one  must  be  careful  to  appl}'  the  bandages  loosely,  so  that  after  drying 
they  do  not  become  too  tight.  Cotton  hose  can  also  be  used  beneath 
the  gypsum  ;  it  is  drawn  over  the  extremity  like  tights  ;  it  is  cheap,  and 
fits  exceedingly  well  without  forming  wrinkles.  AVhen  necessary,  two 
or  three  layers  of  this  material  may  be  put  on  over  each  other.  The 
roller  gypsum  bandages  are  then  allowed  to  soak  in  water  about  a 
quarter  of  a  minute,  or  until  no  more  air  bubbles  are  given  off.  The 
bandage  is  then  squeezed  dry  and  applied  to  the  part  in  question  as 
loosely  as  possible.  It  should  never  be  drawn  tight,  as  this  will  cause 
the  bandage  to  become  too  narrow,  and  may  subsequently  impede  the 
circulation  in  the  limb.  There  is  no  need  of  making  a  reverse  with  the 
gypsum  bandage,  as  a  few  wrinkles  do  no  harm  and  can  be  smoothed 
out  by  rubbing  the  bandage  with  the  hand,  and  thus  causing  the  dress- 
ing to  conform  accurately  to  the  shape  of  the  limb.  After  about  three 
or  four  layers  of  gypsum  bandage  have  been  applied,  a  thin  layer  of 
gypsum  paste  can  be  added  ;  it  is  made  by  mixing  together  gypsum 
powder  and  water  in  about  equal  proportions.  This  layer  is  spread  on 
and  smoothed  over  with  the  palm  of  the  hand,  the  smoothing  process 
being  continued  until  the  dressing  looks  as  though  made  in  one  piece. 
The  gypsum  paste  should  not  be  put  on  too  thick,  for  fear  of  making 
the  dressing  very  heavy,  and  I  frequently  do  not  use  it  at  all.  Plenty 
of  bandage  and  not  too  much  plaster  is  my  maxim.  The  edges  of  the 
dressing  are  best  treated  by  turning  up  the  projecting  underlying  ma- 
terial (cotton  or  bandages)  like  a  cuff  and  securing  it  to  the  outer 
surface  of  the  splint  with  a  turn  of  the  plaster  bandage  or  a  little  of 
the  paste. 

Even  while  the  bandages  or  outer  layer  of  gypsum  paste  are  being 
smoothed  down  with  the  hand,  it  will  be  noticed  that  the  dressing  has 
become  firmer.  In  the  next  few  minutes  it  becomes  noticeably  warm 
and  at  the  same  time  perfectly  hard,  but  not  till  two  or  three  hours 
later  will  the  dressing  be  completely  dry.     By  the  addition  of  some 


218 


THE  APPLICATION  OF   IMMOBILISING   DRESSINGS. 


crystalline  substance,  like  cliloi-ide  of  sodium  or  alum,  the  hardening 
of  the  gypsum  can  be  accelerated.  If  it  is  desired  to  make  the  plaster 
dressino-  water-tight,  its  external  surface  can  be  painted  with  a  solution 
of  resin  in  ether — one  to  four  (Mitscherlich) — or  a  water-glass  bandage 
may  be  placed  over  the  gypsum ;  this  latter  method  is  the  best.  It 
makes  the  gypsum  dressing,  particularly  when  ap])lied  to  children, 
exceedingly  durable.     For  increasing  the  strength  of  the  i)]aster  dress- 


FiG.  195. — Tliin  splint  of  wood  used  for 
strengthening  a  plaster-of-Paris  dressing, 


Fig.  196.— FciK-stniti-d  iihister  dres;.! 
pended  in  a  wooden  frame. 


ing  the  latter  is  often  made  to  include  thin,  pliable  strips  of  wood 
(Fig.  195),  or  splints  made  of  papier-mache,  wood,  zinc,  or  wire.  If  it 
is  not  desirable  to  cover  in  some  portion  of  the  body  by  the  plaster 
dressing  on  account  of  wounds,  fistulse,  etc.,  a  fenestrum  (Fig.  196)  can 
be  cut  out  over  this  portion,  the  location  of  which  may  be  previously 
indicated  by  placing  over  it  a  piece  of  cotton  or  a  flat  disk  having  a 
projecting  nail.     The  edges  of  the  fenestrum  can  be  smoothed  off  with 

a  little  plaster  paste  or  asphalt, 
to  prevent  fluids  such  as  pus 
from  gaining  access  to  the  under 
surface  of  the  dressing.  When 
a  considerable  portion  of  an  ex- 
tremity, such  as  the  knee-  or 
elbow-joint,  is  to  be  left  out  of 
the  splint,  two  plaster  cases 
should  be  applied,  one,  for  ex- 
ample, to  the  thigh,  the  other  to 
the  leg,  joined  together  by  an 
iron  rod,  which  can  also  be  cov- 
ered with  plaster  (Fig.  197) ; 
telegraph  wire  can  be  used  in 
the  same  manner.  Under  other 
conditions,  when,  for  instance, 
one  wishes,  at  the  same  time,  to  suspend  the  extremity,  another  plan  is 
carried  out  which  is  represented  in  Figs.  198  and  199.  Two  plaster 
cases  are  applied  to  the  extremity  while  it  lies  upon  a  suitable  splint, 


Fig.  197.- 


-Interrupted  plaster  dressing  (for  the 
knee). 


Fig.  198. — Interrupted  plaster  dressing,  suspended 
(upper  extremity ). 


§54.]  IMMOBILISATION    DRESSINGS   OF   HARDENING   SUBSTANCES,    viy 


and  a  telegraph  wire,  having  been  bent  into  pro])er  sliape,  connects  the 
two  separate  bandages  on  the  dorsal  surface  of  the  linil)  and  is  covered 
by  plaster  bandages  (see  Figs. 
207,  208,  209).  In  the  same  way 
two  plaster  cuffs  can  be  provided 
with  a  hinge  so  as  to  form  a 
joint,  which  is  useful  in  the  after- 
treatment  of  a  resected  elbow 
(Heine). 


Fig.  199. — Interrupted  pla.ster  dressing,  suspended 
(lower  extremity). 


Gradual  stretching  of  Contracted 
Joints  by  the  Plaster  Dressing. — 
The  plaster  dressing  can   also  be 

used  for  gradual  extension  of  contracted  joints.  A  plaster  case  is  applied  to 
the  lower  extremity  and  an  oval-shaped  fenestrum  cut  over  the  region  of  the 
anterior  surface  of  the  knee,  and  at  the  same  time  the  splint  is  cut  behind 
transversely  across  the  popliteal  space.  Day  by  day  continually  larger  pieces 
of  cork  are  then  wedged  into  the  posterior  line  of  division  in  the  splint,  and 
thus  the  knee-joint  is  gradually  extended. 

Gypsum  Dressing  combined  with  an  Antiseptic  Dressing.— The  great 
advances  in  modern  aseptic  surgery  render  possible  the  frequent  combina- 
tion of  plaster  with  antiseptic  dressings.  After  osteotomy,  for  instance,  of 
the  femur,  we  cover  the  open  wound  with  an  aseptic  protective  dressing  and 
then  place  over  this  a  plaster  splint,  which  is  left  undisturbed  till  the  wound 
has  healed,  or  from  four  to  six  weeks.  We  often  adopt  a  similar  practice 
in  the  after-treatment  of  resected  joints,  allowing  the  wound  to  remain  par- 
tially open,  or  not  sutvired  tight. 
In  other  cases  of  joint  resection  the 
plaster  bandages  are  not  placed 
over  the  antiseptic  protective  dress- 
ing till  about  three  to  five  days 
after  the  operation,  when  the  drains 
are  taken  out.  In  compound  frac- 
tures the  plaster  splint  is  combined 
with  the  antiseptic  dressing  at  the 
earliest  possible  moment.  Berg- 
mann's  and  Reyher's  experiences 
show  that  gypsum  dressings  will 
become  of  the  greatest  use  in  army 
surgery.  These  surgeons  obtained 
most  excellent  results,  during  the 
Russo-Turkish  war,  from  combined 
antiseptic  and  plaster  dressing  for 

the  treatment  of  gunshot  wounds  of  bone.  In  addition  to  the  plaster  bandage 
dressing,  as  it  is  ordinarily  described,  mention  should  be  made  of  the  follow- 
ing modifications: 

Modifications  of  the  Gypsum  Dressing.— Compresses,  pieces  of  cloth,  or 
parts  of  the  patient's  clothing,  are  dipped  in  plaster  paste  and  either  laid 


Fig.  20O.^Gypsuni-liomp  splint  (Schonbom  and 
Beely). 


Fig.  201. — Case  for  the  lower  extremity,  with 
straps,  buckles,  and  a  hinge-joint  on  the  op- 
posite side. 


220  'i'HE  APPLICATION   OP   LM MOBILISING   DRESSINGS. 

around  an  extremity  or  fastened  on  with  bandages  after  previously  enveloping 
the  limb  in  some  buffer  dressing.  These  gypsum  cataplasms  are  highly  rec- 
ommended by  Pigoroff,  Adelmann,  Szymanowski  and  others  for  making  a 
hasty  dressing  to  suffice  during  transportation  of  the  patient.  Beely  and 
Schonborn  dip  strands  of  hemp  in  plaster  paste,  thus  making  gypsum-hemp 
splints  to  which  buttons  can  be  attached  for  purposes  of  suspension  (Fig. 
200).  Splints  which  are  made  in  a  similar  manner  with  cotton  are  more  com- 
fortable, and  are  adapted  especially  for  making  Braatz's  spiral  splint  for  frac- 
ture of  the  radius  (see  Spec.  Surg.).  Cotton  impregnated  with  gypsum,  or 
the  gypsum  i^lates  of  Fickert,  are  dipped  in  hot  water  before  they  are  applied 
to  the  limb.  They  harden  after  some  eight  to  ten  minutes.  Gypsum  powder 
is  also  sewed  up  in  a  sack,  and  when  soaked  in  water  it  forms  a  mass  which 
readily  becomes  moulded  to  the  limb,  and  when  dried  makes  a  splint  which 
can  easily  be  taken  off  (Zsigmondy).  By  sewing  together  two  of  these  sacks 
full  of  plaster  longitudinally  upon  one  side  and  laying  them  around  an  ex- 
tremity and  then  wetting  them,  a  gypsum  splint  is  formed  having  the  sewed 
connection  between  the  two  bags  as  a  hinge  to  facilitate  its  removal  from  the 
limb.  In  a  similar  manner  immobilisation  appliances  can  be  made  in  two  or 
more  parts  which  can  be  fastened  on  a  limb  with  bandages  or  secured  with 
straps  and  buckles  (Fig.  201).  In  this  way  most  excellent  splints  can  be 
fashioned  of  gypsum  or  other  hardening  material,  such  as  waterglass,  and 
also  many  kinds  of  supporting  apparatus  can  be  substituted  for  those  manu- 
factured by  instrument  makers. 

Auschiitz  advises  that  the  straw  splints  which  have  long  been  employed 
by  stretcher  bearers  as  a  transportation  dressing  be  soaked  in  plaster  paste 
and  bound  on  with  a  wet  gauze  bandage.  The  plaster  cast  is  the  oldest  method 
of  applying  the  gypsum  dressing,  but  is  at  present  no  longer  used.  It  origi- 
nated in  the  Orient,  was  employed  by  the  Arabians  of  ancient  times,  and 
was  very  generally  used  in  Europe  at  the  beginning  of  this  century,  especial- 
ly by  Froriep  and  Dieffenbach.  The  skin  of  the  extremity  was  first  covered 
with  oil  and  then  enclosed  in  a  wood  or  sheet  metal  case  which  was  poured 
full  of  plaster  paste.  Finally,  the  limb  was  taken  from  the  case  surrounded 
by  the  plaster  mould. 

Back  Support. — For  the  application  of  the  plaster  dressing  to  the 
lower  extremity,  and  particularly  to  the  thigh  and  pelvis,  extension 
and  supporting  appliances  are  of  great  utility.  They  render  the  pelvis 
accessible  on  all  sides,  and  prevent  a  fractured  femur  from  becoming 
shortened.  The  simplest  form  of  pelvic  support  is  represented  in  Fig, 
117 ;  it  is  Yolkmann's  cushioned  support,  which  is  placed  under  the 
sacrum.  A  footstool  used  in  the  same  way  forms  an  excellent  back 
rest.  The  patient  is  secured  in  the  horizontal  position,  with  extension 
aj>plied  to  the  leg  and  counter  extension  to  the  axilla.  Billroth,  Bar- 
deleben  and  others  have  invented  excellent  back  rests. 

Extension  appliances  are  sometimes  very  useful  accessories  in  ap- 
plying a  plaster  splint  to  the  thigh,  especially  if  the  fracture  is  oblique 
and  there  is  marked  shortening.     Liicke,  Heine  and  Bruns  have  in- 


§54.]    IMMOHILISATIUN    DUlvSSlXG.S   OF   1IARDP]NING   SUBSTANCES.    221 


J 


.0^ 


vented  extension  ai)j)lian('es  for  this  purpose.  Pulleys  are  used,  par 
ticularly  for  the  lower  extremity,  in  the  application  of  plaster  splints 
Special  contrivances  for  extension  are,  as 
a  rule,  unnecessar}-,  and  the  hands  of  an 
assistant  will  ordinarily  be  found  suffi- 
cient. Plaster  dressings  are  applied  to 
the  thorax  chiefly  in  treating  fractures  of 
the  ui)per  end  of  the  humerus  (Fig.  202). 
A  plentiful  amount  of  cotton  padding, 
with  a  wad  of  cotton  in  the  axilla,  is  first 
applied  and  secured  with  a  mull  bandage, 
while  the  forearm  is  held  across  the 
thorax  with  the  elbow  bent  at  a  right  an- 
gle ;  then  the  plaster-splint  dressing  is 
placed  over  the  padding,  enveloping  tlie 
thorax,  the  forearm,  and  the  fractured 
arm. 

Removal   of  Plaster   Splints.— PZa5^(?r 
splints   or   dressings  are  taken  off  with    ^'''•tr/-;r.?K?\hora?:Xari 
the  assistance  of  a  knife  made  especially  for  frictures  of  the  upper  part  of 

i  J  the  humerus. 

for    the    purpose   (Fig.    203),   and    with 

shears  (Fig.  204,  «,  V).  Small  ordinary  saws,  as  well  as  circular  saws, 
have  also  been  recommended  for  this  purpose.  The  plaster  knife 
should  be  held  with  its  edge 
somewhat  at  an  angle  to  the 
splint,  so  as  to  cut  it  obliquely  to 
the  external  surface  ;  or  two 
oblique  longitudinal  incisions  are 
made  in  the  plaster  forming  a 
V-shaped  gutter.  The  deeper 
layers  of  the  splint  should  be  cut 
with  the  plaster  shears.  By  moi^  t- 
ening  the  whole  splint  with  water, 
or  only  along  the  line  where  it  is 
to  be  cut,  the  cutting  process  is 
made  much  easier.  After  the 
plaster  dressing  has  been  cut 
through  longitudinally,  the  edges 
of  the  incision  are  pulled  apart 
and  the  limb  is  lifted  out.  Plas- 
ter splints  which  have  been  cut  and  taken  off  may,  when  desired, 
be  replaced  and   used   again.     In  such  cases  it  is  best  to  connect  the 


Fig.  203.— 

Knife  for 

plaster 

dressintrs. 


\v 


Fig.  204. — Sci-ssors  for  plaster 
dressiutcs. 


222  THE  APPLICATION  OP  IMMOBILISING   DRESSINGS. 

edges  with  plaster  paste  or  adhesive  plaster,  over  which  plaster  paste  is 
applied,  and  thus  the  edges  of  the  splint  are  less  likelj  to  become  sepa- 
rated. 

Tripolith  Dressing.— Langenbeck  has  recommended  ti-ipolith  as  a  sub- 
stitute for  gypsum  or  plaster  of  Paris.  Tripolith  is  a  greyish,  cement- 
like  substance  consisting  of  gypsum  with  a  little  silicate  of  aluminium  and 
charcoal  or  coke.  The  properties  of  tripolith  are  in  general  the  same  as 
dehydrated  gypsum,  but  ti'ipolith,  according  to  Laugenbeck,  is  somewhat 
lighter  and  cheaper  than  gypsum ;  it  also  hardens  a  little  more  rapidly,  and 
when  hai'd  will  not  absorb  water.  The  tripolith  dressing  is  applied  with 
bandages,  like  plaster  of  Paris. 

The  Starch  Dressing. — Starch  paste  was  recommended  by  Sentin,  in 
1834,  for  the  manufacture  of  stiff  dressings.  •  A  starch  dressing  is  easily 
applied,  agreeable  to  the  patient,  cheap  and  light,  but  it  has  the  disad- 
vantage of  requiring  from  one  to  three  days  to  become  dry,  and  for 
this  reason  starch  dressings  have  been  supplanted  by  plaster  in  the 
treatment  of  fractures.  The  starch  bandage  is  frequently  combined 
with  pasteboard  splints  in  fracture  of  the  arm,  and  is  also  used  alone  in 
the  later  treatment  of  any  fracture. 

The  method  of  applying  the  starch  bandage  is  briefly  as  follows : 
A  padding  is  laid  on  the  skin  in  the  shape  of  a  flannel  bandage,  and 
the  bony  prominences  are  protected  from  too  much  pressure  from  the 
starch  dressing  by  a  layer  of  cotton.  A  soft  mull  bandage  is  applied 
over  the  flannel,  and  then  a  layer  of  starch  or  bookbinders'  paste  is 
spread  over  the  mull.  Several  strips  of  pasteboard  of  various  sizes  are 
rendered  soft  and  pliable  by  soaking  in  warm  water,  and  are  included 
in  the  dressing  in  such  a  way  as  to  encase  the  limb,  leaving  short  inter- 
vals between  each  strip.  The  pasteboard  is  then  covered  evenly  with 
the  starch  paste,  and  over  this  is  placed  a  mull  bandage,  which  receives 
another  layer  of  starch  paste.  Some  three  to  four  layers  are  enough, 
and  the  strips  of  pasteboard  can  be  used  in  a  double  layer,  especially  if 
they  are  narrow.  Finally,  a  dry  mull  bandage  is  applied  to  prevent 
the  starch  paste  from  adhering  to  the  clothes,  or  a  bandage  in  the  form 
of  a  bag  may  be  used,  as  well  as  black  silk,  to  improve  the  appearance 
of  the  dressing.  The  dressing  is  cut  open  with  a  stout  pair  of  shears, 
and  can  then  be  used  as  a  removable  splint  in  the  same  way  as  described 
for  the  plaster  splints  (Fig.  201). 

Cotton-Starch  and  Paper-Starch  Dressing. — The  cotton-starch  dressing  of 
Burggraeve  and  tbe  paper-starch  dressing  of  Laugier  and  Heyfclder  are 
modifications  of  the  ordinary  simple  starch  dressing.  The  latter  is  made  by 
including  strips  of  paper  in  the  bandages  and  covering  them  with  starch 
paste.     In  the  cotton-starch  dressing  the  limb  is  enveloped  in  from  two  to 


g  54.]  IMMOBILISATION   DRESSINGS  OF  IJAKDENING   SUBSTANCES.   223 

four  rather  thick  layers  of  cotton  wool,  over  which  is  applied  the  starch- 
paste  clressiuji:,  with  strips  of  pasteboard  softened  in  warm  water,  and  made  to 
fit  the  extremity  by  wrapping  over  them  a  mull  bandage  in  the  manner  just 
described  (page  222). 

The  Water-Glass  Dressing  (Schrautli,  Seliuli,  1S57)  is  very  easily  put 
on,  is  cheap,  durable,  hard,  and  light,  and  is  also  impervious  to  water, 
but  has  the  disadvantage  of  rccjuiring  twelve  to  twenty-four  hours  to 
harden.  It  is  best  to  use  a  freshly  made  solution  of  neutral  silicate  of 
potassium  having  a  specific  gravity  of  from  1-35  to  1-40.  This  dress- 
ing, like  the  i)laster  of  Paris,  is  applied  in  prepared  bandages  which 
have  been  saturated  with  water  glass  having  the  consistency  of  syrup. 
About  five  to  six  layers  of  the  w^ater-glass  bandages  are  sufficient.  It 
is  best  to  use  a  flannel  bandage,  or  cotton  and  a  mull  bandage,  as  pad- 
ding to  lie  beneath  the  water-glass  bandages.  The  skin  should  be  care- 
fully protected  from  contact  with  the  water  glass,  as  the  latter  is  liable 
to  cause  a  very  obstinate  eczema,  particularly  when  old  solutions  are 
used.  Furthermore,  the  water-glass  bandages  should  not  be  carried 
beyond  the  limits  of  the  protective  padding,  as  the  sharp  edges  of  the 
splint  may  cut  into  the  skin.  The  water-glass  splint  can  also  be 
strengthened  by  including  in  it  thin  strips  of  wood  or  other  material. 
It  is  an  excellent  plan  to  mix  with  the 
water  glass,  gypsum,  chalk,  cement,  etc. 
These  substances  make  the  dressing 
liarden  more  rapidly  and  render  it  very 
firm  (Bohm,  Konig,  the  author).  Ban- 
dages are  soaked  in  the  thick  paste  and 
applied  as  in  the  plaster  dressing,  or  the 
paste  made  from  water-glass  powder  is 
applied  with  a  brush  to  the  bandages 
after  they  have  been  put  in  place.  At 
the  end  the  entire  dressing  can  be 
dusted  with  the  dry  powder  and  painted 
over  with  alcohol,  which  gives  it  a 
hard,  glassy  covering.  The  water-glass 
splint  is  much  used  in  the  treatment 
of  inflamed  joints,  fractures,  etc.,  and 
can  also  be  made  into  hinged,  remov- 

,1  ,.    ,         TT-  1  ^  TT   j-i       ^  Fig.  205. — Bandaares,  artificial  limbs,  and 

able  splints.    Kappeler  and  Hatter  have  corsets,  made  of  water  glass. 

shown  that  a  number  of  apparatus,  arti- 
ficial limbs,  corsets,  articulated  splints, etc., can  be  made  of  water  glass* 


*  For  the  further  description  of  these  appliances,  see  Kappeler  and  Hafter,  Deutsch. 
Zeitschr.  fiir  Chir.,  Bd.  vii.,  P.  129. 


•224-  THE   APPLICATION    OF   IMMOBILISING   DRESSINGS. 

(Fig.  205).  Fig.  205,  a  and  b,  represent  water-glass  splints  for  the 
lower  extremity,  provided  with  straps,  buckles,  strips  of  caoutchouc, 
and  fenestras  suitably  placed  for  permitting  movement  of  the  joints. 

<?  is  a  contrivance  of  Taylor's  for  use  in  coxitis  (see  Spec.  Surg.) ; 
d  represents  a  prothetic  apparatus  for  amputation  of  the  arm  ;  6  is  a 
corset,  andyis  another  of  Taylor's  devices  for  kyphosis;  <Z  and  e  are 
perforated  with  holes, to  make  the  apparatus  light  and  accessible  to  air. 

The  manufacture  of  immobilisation  appliances  from  moulded  felt 
and  gutta-percha  has  been  described  before  (see  pages  212,  213). 

Dextrine  Dressing, — Amongst  the  other  materials  which  have  not  found 
any  very  general  use  brief  mention  may  be  made  of  the  dextrine  dressing  of 
Velpeau  (1838).  It  is  applied  in  the  same  manner  as  the  starch  dressing,  one 
hundred  parts  of  dextrine  being  mixed  with  sixty  parts  of  spirits  of  camphor 
and  fifty  parts  of  water.  This  dressing  takes  from  four  to  seven  hours  to 
dry. 

Glue  Dressing. — The  glue  dressing  (Vanzetti,  1846)  hardens  very  slowly. 
Strips  of  linen  or  roller  bandages  of  linen  or  muslin  are  spread  on  one  side 
with  joiner's  glue,  allowed  to  dry,  and  then  rolled  into  bandages  with  the 
glue  side  out.  The  bandages  immediately  before  use  are  dipped  in  hot  water 
and  applied  to  any  desired  region  over  a  protective  padding  bandage.  The 
same  procedure  can  be  adopted  as  in  starch  or  water  glass  dressings,  which 
consists  in  simply  saturating  bandages  and  splints  with  the  glue  after  they 
have  been  applied.  Thin  wooden  or  pasteboard  splints  can  be  incorporated 
in  the  dressing  to  strengthen  it. 

Magnesite  Dressing. — The  magnesite  dressing  is  most  excellent,  firm,  and 
durable.  Finely  powdered  magnesite  and  water  glass  are  mixed  into  a  thick 
paste.  The  method  of  applying  this  dressing,  which  requires  some  twenty- 
four  to  thirty-six  hours  to  dry,  is  practically  the  same  as  for  the  starch  or 
water-glass  dressing — i.  e.,  either  the  magnesite  water-glass  paste  is  painted 
with  a  brush  over  the  dry  mull  bandages,  or  else  the  mull  or  cotton  bandages 
are  first  soaked  in  the  paste  and  then  applied  to  the  extremity  over  a  padding 
of  flannel  bandages. 

Cement  Dressing. — In  the  application  of  the  cement  dressing  a  mixture  of 
one  part  of  cement  to  two  to  three  parts  of  gypsum  is  employed,  and  this  is 
then  applied  like  the  gypsum  or  plaster-of-Paris  dressing. 

Other  Dressings. — The  gum  dressing  (Lorinser)  is  made  of  lime  or  cement 
dissolved  in  casein,  albumen,  gum  arabic,  glue  and  other  materials  by  tbe 
addition  of  water. 

The  gum-chalk  dressing  of  Bryant  and  Wolfler  is  made  of  a  paste  of  gum 
arabic  and  chalk  powder.  There  is  also  a  collodion  dressing,  a  resin  dress- 
ing, with  or  without  wax,  a  parafSne  and  stearine  dressing,  but  so  far  all  these 
have  not  come  into  general  use. 

§  55.  The  Method  of  applying  Extension  by  a  Weight— As  we  shall 
see  later  on,  permanent  extension  is  much  used,  for  example,  in  chronic 
inflammations  of  joints  and  in  fractures.     The  method  of  applying  ex- 


§55.]    THE  METHOD  OP  APPLYING  EXTENSION  BY  A  WEIGHT.      225 


Fig.  206. — Adhesive-plaster  extension  apparatus. 


tension  bv  a  weight  is  tlie  most  generally  used  of  all,  and  for  this  we 
hiive  to  thank  tlie  American  surgeons  Buck,  Crosby  and  others,  as 
well  as  the  German 
surgeons  Volkmann 
and  Bardenlieuer. 
The  pulling  of  the 
fragments  apart  by  a 
weight  is  very  fre- 
quently used  for  the 
lower  extremity  in 
fracture  of  the  femur 
and  for  diseases  of  the 
hip  and  knee  joints, 
and  consequently  we 
must  describe  it  some- 
what at  length. 

Extension  by  a 
Weight  for  the  Lower  Extremity. — The  extension  dressing  for  a  fracture 
of  the  neck  of  the  femur  in  the  form  of  an  adhesive-plaster  extension 
contrivance  is  begun  in  the  case  of  adults  with  the  application  of  a 
strip  of  adhesive  plaster,  from  three  fingers  to  a  hand-breadth  in  width, 
along  the  inner 
and  outer  side  of 
the  leg,  in  such  a 
way  that  the  mid- 
dle of  the  strip 
extends  in  the 
form  of  a  loop 
about  a  hand- 
breadth  bej^ond 
the  sole  of  the 
foot.  Before  ap- 
plying the  adhe- 
sive plaster  it  is  a 
good  plan  to  shave 
off   the   hairs,  to 

prevent  the  latter  from  sticking  to  the  plaster  ;  then  strips  of  adhesive 
plaster  (or  a  flannel  bandage)  are  placed  circularly  around  the  leg  over 
the  lateral  strips  at  intervals,  or  overlapping  each  other,  beginning  just 
above  the  malleoli  and  going  to  the  head  of  the  fibula.  The  free  ends 
of  the  adhesive  plaster,  which  should  reach  to  the  middle  of  the  thigh, 
are  then  split  longitudinally  with  scissors  into  two  or  three  strips, 
IG 


207. — Extension  with  suspension  by  means  of  a  ^ypsum-liemp 
splint  or  a  telegraph-wire  splint  for  fractures  of  the  femur. 


2M  THE  APPLICATION  OF  IxMMOBlLISING  DRESSINGS. 

which  are  turned  down  from  the  thigh  and  also  secured  about  the  le^ 
with  several  circular  strips  of  adhesive  plaster.*  In  this  manner  the 
lateral  strips  of  adhesive  plaster  are  secured  to  the  leg  very  tirmly.  I 
avoid  placing  strips  circularly  around  the  leg  in  the  region  of  the  head 
of  the  fibula,  as  this  practice  sometimes  has  been  known  to  cause  a 
pressure  paralysis  of  the  external  popliteal  nerve.  The  adhesive  plas- 
ter must  be  made  of  strong  material,  to  withstand  the  strain  put  upon 
it,  and  consequently  it  may  be  advisable  to  make  the  lateral  strips  of 
two  or  three  thicknesses.  In  the  loop  made  by  the  adhesive  plaster 
below  the  foot  a  small  piece  of  board  is  fastened  in  place  to  prevent 
chafincr  of  the  skin  over  the  malleoli.  Throus-h  a  hole  in  the  centre 
of  this  board  is  passed  the  rope  to  which  the  extension  weight  is  at- 
tached. The  rope  is  fastened  to  the  board  by  knotting  it  on  the  side 
next  the  foot,  or  it  may  simply  be  attached  by  a  hook  (Figs.  206, 
209).  The  rope  to  which  the  weight  is  fastened  for  making  the  exten- 
sion runs  over  two  rollers  fastened  to  the  patient's  bed  (Fig.  206). 
This  dressing  can  be  made  more  firm  and  durable  by  applying  over  it 
a  layer  of  mull  bandage,  and  over  this  a  gauze  bandage,  or,  better  still, 
a  water-glass  or  chalk-water-^lass  dressing.  To  lessen  the  amount  of 
the  chafing  to  which  the  limb  is  subjected,  and  to  regulate  the  position 
of  the  foot,  it  is  a  good  plan  to  use  Volkmann's  sliding  foot  rest  (Fig. 


Fig.  208. — Vertical  suspension  with  a  plaster  dressing,  the  knee  being  bent  at  a  right  angle. 

206),  which  consists  of  a  tin  gutter  splint  for  the  leg,  padded  with  cot- 
ton or  jute,  and  having  a  removable  foot-piece  attached  to  a  wooden 
cross-bar.     The  cross-bar  slides  on  two  longitudinal  strips  of  wood. 

*  In  this  country  the  strips  are  not  turned  down,  but  left  applied  to  at  least  half 
the  length  of  the  thigh  above  the  knee,  to  lessen  the  traction  on  the  ligaments  of  the 
knee-joint. — [  Trans.] 


§55.]    THE   METHOD   OF   APPLYING    EXTENSION    BY    A   WEIGHT.      227 


Other  sliding  foot  rests  have  been  invented  hy  Riedel  and  AVahl.     If 
N'olkniann's  contrivance  is  employed,  any  hardening  dressing,  such  as 


/^:^ 


Fig.  209. — Vertical  extension  for  fracture.-^  uf  the  femur 
in  eliildren. 


Fig.  210. — Extension  at 
the  shoulder  bv  a  weitrlit. 


the  water-glass  bandage,  mnst  of  course  be  applied  so  as  to  inc" 

leg  splint.     The  weight  of  the  body  is  ordinarily  employed  for 

counter   extension,  the   patient 

}>eing  kept,  if    possible,  in  the 

horizontal    position    while    the 

foot  of  the  bed  is  raised  by  a 

couple  of  blocks  of  wood  ;  or  a 

pelvic  or  perineal  girdle,  made, 

for    example,   from    a    rubber 

bandage,  can  be  carried  around 


ude  the 
makiner 


Fig.  211. — E.vtension  by  a  weight  applied  to  the  upper  arm  (Lossen);  a,  gutter  splint. 

the  patient's  perinppum.  thence  to  the  head  of  the  "bed,  and  attached  to 
a  weight  by  a  cord  running  over  a  couple  of  rollers. 

As  adhesive  plaster  is  sometimes  uncomfortable,  and  may  cause  a 


228 


THE  APPLICATION  OF  IMMOBILISING   DRESSINGS. 


troublesome  eczema,  emplastrum  cerussae  may  be  used  in  its  place ;  or 
perhaps  a  better  plan  is  to  enclose  the  limb  in  a  flannel  bandage,  and  to 
attach  to  this  extension  strips  made  of  pieces  of  linen  cloth  ;  or  a  strong 
and  not  too  elastic  rubber  bandage  may  be  sewed  laterally  to  the  turns 

of  the  flannel  bandage.  Exten- 
sion may  also  be  combined  with 
some  one  of  the  various  kinds 
of  immobilising  dressings,  such 
as  plaster  of  Paris,  Recently 
the  cord  for  exerting  the  trac- 
tion has  been  attached  by  means 
of  hooks  and  cross-bars  to  rub- 
ber tubing  tilled  with  air  ap- 
plied around  the  region  just 
above  the  malleoli. 

In  the  after-treatment  of 
cases,  such  as  a  hi])-joint  resec- 
tion, where  extension  is  only 
required  at  night,  gaiters  are 
applied  reaching  to  the  middle 
of  the  thigh  and  having  a 
leather  foot-piece  to  which  is 
fastened  the  cord  for  exerting 
the  ti-action. 

If  it  is  desired  to  apply  ex- 
tension to  the  thigh  in  a  somewhat  abducted  position,  as  after  resection 
of  the  head  of  the  femur,  rollers  can  be  attached  to  a  board,  which 


Fig.  212. — Extension  by  a  weight  applied  to  the 
upper  extremity  (Hofmokl).  In  extension  by 
weight  of  the  upper  arm  tlie  loops  1  and  3  are 
not  u.sed  ;  in  ease  i;f  the  tnrearm  2  is  not  used  ; 
the  extension  is  then  made  at  3  and  counter- 
extension  at  1. 


Cxti-'iisiiin  of  the  forearm  and  hand  (Langenbeek ). 


may  be  fastened  with  screws  to  any  desired  part  of  the  bed,  while  the 
cord  for  exerting  the  traction  is  carried  over  a  wooden  frame  placed  in 
the  neighbourhood. 

Frequently,  in  cases  of  fracture  of  the  lower  extremity,  extension  is 
combined  with  suspension,  as  illustrated  in  Figs.  207,  208,  and  209.  It 
requires  no  further  explanation. 


^55.]    THE   METFTOD  OP   APPLYING    EXTENSION    BY    A    WEIGHT.      229 

Extension  by  a  Weight  for  the  Tipper  Extremity  is  carried  out  by 
inoiuisufadhc.-ive  plaster  applied  to  the  bhoulder-juiut  and  arm,  accord- 


FiG.  214. — Permanent  extension  by  weicrlit  by  means  of  Glisson's  sling  for  cases  of 

spondylitis. 

iiiir  to  the  methods  of  Bardenhener  and  Hamilton,  or  of  Lossen  or 
llofmokh  Extension  upon  tlie  u]iper  extremity  has  by  no  means  the 
importance  that  it  has  upon  the  lower.  Hamilton's  extension  at  the 
shoulder-joint  (Fig.  210)  is  applied  by  means  of  adhesive  plaster  and  a 


Fig.  215.  —  Falkson's 
sling  for  the  chin 
and  back  of  the 
neck,  made  of  ce- 
russa  plaster  and 
used  for  e.xtension 
of  the  vertebral 
column. 


Fig.  216.— Fixation  and  extension  of  the  cervical  vertebrae  for 
spondylitis  cervicalis  and  dorsalis  by  means  of  the  jury-mast 
(Sayre). 


weight,  while  counter  extension  is  made  with  a  crutch  in  the  axilla,  the 
crutch  being  supported  by  a  belt  around  the  waist.  Lossen's  extension 
for  the  arm  (Fig.  211)  is  applied  by  laying  the  arm  on  a  splint  which  is 


230 


THE  APPLICATION   OP  IMMOBILISING   DRESSINGS. 


fastened  to  tlie  patient's  bed.  The  way  in  which  the  traction  is  ex- 
erted by  adliesive-plaster  strips  is  represented  in  the  figure  and  needs 
no  further  description.  Hofmokl  has  also  devised  an 
excellent  apparatus  for  applying  extension  by  a  weight 
to  the  upper  extremity  (Fig.  212).  There  is  seldom 
any  need  of  applying  extension  at  the  elbow-joint,  but 
for  the  forearm  and  wrist-joint  Langenbeck's  method 
(Fig.  213)  can  be  used.  Extension  by  a  weight  can 
also  V)e  employed  for  the  metacarpus  and  fingers  by 
means  of  loops  of  adhesive  plaster.  Extension  by 
suspending  the  arm  is  illustrated  in  Fig.  108. 

Extension  by  a  Weight  for  the  Vertebrae. — The  fol- 
lowing is  a  brief  description  of  the  methods  of  using 
extension  for  the  vertebrae :  For  fractures  and  tuber- 
cular inflammation  of  the  vertebrae,  Glisson's  leather 
sling  with  a  metal  arch  (Fig.  214)  is  employed,  or 
Falkson's  chin-neck  sling  of  emplastrum  cerussse  (Fig. 
215).  E,  Fischer's  suggestion  is  excellent :  A  four- 
cornered  piece  of  cloth  is  provided  with  openings  for 
the  face  and  neck  ;  it  is  then  padded  in  the  region  of  the  chin  and  back 
of  the  neck,  and  the  four  corners  of  the  cloth  are  brought  together  over 
the  top  of  the  head  and  connected  with  the  cord  used  for  exerting  the 
traction.  Counter  extension  is  furnished  by  the  weight  of  the  body — 
i.  e.,  the  head  of  the  V)ed  is  raised,  or  extension  is  applied  to  the  legs. 


Fk;.  Ji:.  I'llt-corsot 
with  jury  iiia^t  for 
ti  xation  of  the  head 


vica 


pon 
lis. 


Fig.  218.— Position  of  the  patient  in  Rauchfuss's  hammock  in  cases  of  spondylitis  tuberculosa. 


In  cases  of  tul)ercular  inflammation,  for  example,  of  the  cervical 
vertebrae,  the  latter  may  be  fixed  and  extended  by  means  of  the  jury 
mast  cor.set  (Sayre,  Figs.  216,  217).  For  extension  of  the  lumbar 
and  dorsal  vertebrae  it  is  best  to  use  the  weight  of  the  patient's  body 
by  placing  him  either  in  a  Rauchfuss  hammock  (Fig.  218)  or  in  a  Bar- 


g55.]    THE  METHOD  OP  APPLYING   EXTENSION   BY   A   WEIGHT.     231 

well's  sling.  The  methods  of  applying  these  different  dressings  will  be 
described  in  the  Text-iJook  on  S))eei;d  Surgery. 

The  Amount  of  Force  to  be  used  in  Extension. — The  amount  of  trac- 
tion which  may  be  employed  in  the  different  extension  appliances  varies 
with  tlie  age  of  the  patient  and  the  nature  of  the  disease  or  injur}'. 
For  fractures  of  the  femur  and  hip-joint  infiannnations  in  small  chil- 
dren, one  to  two  to  three  kilogrammes  are  used  ;  for  children  from  ten 
to  twelve  years  old,  somewhat  more ;  while  in  adults  ten  to  fifteen  kilo- 
grammes may  be  needed. 

Extension  by  Splints. — Extension  by  splints  is  much  less  used  now 
than  was  formerly  the  case.  Reference  will  be  made  in  the  text-book 
on  special  surgery  to  the  splints  used  for  extension  purposes,  especially 
under  the  treatment  of  diseases  of  the  hip-joint. 


THIRD   SECTION. 
SURGICAL  PATHOLOGY  AND  THERAPY. 


CHAPTER   I. 


INFLAMMATION    AND    INJURIES. 


The  phenomena  of  inflammation. — The  histological  changes  which  take  place  in  in- 
flammation.— Causes  of  inflammation. — Symptoms  of  inflammation. — Termina- 
tions.— Diagnosis. — Treatment. — Morphology  and  significance  of  micro-organisms 
(microbes). — Injuries  in  general. — The  histological  changes  which  occur  in  the 
healing  of  a  wound. — The  reaction  following  wounds  and  inflammations. — Fever. — 
Shock, — Delirium  tremens. — Delirium  nervosum. — Disturbances  which  may  arise 
during  the  healing  of  a  wound. — Infection  of  wounds. — Inflammation. — Suppura- 
tion of  the  wound. — Lymphangitis. — Arteritis. — Phlebitis. — Cellulitis. — Erysipe- 
las.— Wound  diphtheria  (hospital  gangrene). — Tetanus. — Septicaemia. — Pyaemia. — 
Infection  by  cadaveric  poison. — Other  kinds  of  infection. — (Anthrax  ;  symptomatic 
anthrax. — Glanders. — Hoof  and  mouth  disease. — Hydrophobia.) — Poisoning  by  in- 
sects, snakes,  etc. — Curare  poisoning. — Appendix  :  Chronic  microbic  diseases. — 
Tuberculosis. — Leprosy. — Actinomycosis. — Syphilis. 

§  56.  Inflammation. — The  physicians  of  antiquity  recognised  the 
four  cardinal  symptoms  of  inflammation  :  Redness  (rubor),  heat  (calor), 
swelling  (tumour),  and  pain  (dolor).  But  these  outward  manifestations 
do  not  throw  light  upon  the  source  and  essence  of  inflammation.  The 
question,  where  the  origin  of  the  process  is  to  be  found,  has  always 
been  a  subject  of  discussion,  and  the  principal  part  in  the  production 
of  inflammation  has  been  ascribed  in  turn  to  the  blood,  to  the  tissues, 
to  the  blood-vessels,  and  to  the  nerves.  Numberless  experiments  have 
been  performed  and  the  most  diverse  theories  have  been  advanced  to 
account  for  the  phenomena  of  inflammation.  Virchow  founded  the 
cellular-pathology  theory,  according  to  which  an  "  inflammatoi-y  irrita- 
tion "  leads  to  definite  changes  in  the  cells.  Cohnheim  ascribed  it  to  a 
probable  molecular  change  in  the  walls  of  the  vessels,  while  Reck- 
linghausen and  Thoma  laid  stress  upon  the  vasomotor  nerves,  and  par- 
ticularly upon  their  centres  located  in  the  inflamed  region.  Of  the 
various  inflammatory  irritants  or  causes  of  inflammation,  micro-organ- 

(233) 


§56.] 


INFLAMMATION. 


233 


isms  and  the  products  of  tlieir  metabolism  should   be  looked  uj^oii  as 
the  most  iniixn-taiit. 

Changes  in  the  Circulation  in  an  Inflamed  District. — In  order  to  un- 
derstand the  nature  of  inflammation,  it  is  best  iirst  to  study  what 
takes  place  in  the  circulatory  system.  Cohnheim  has  shown  how  these 
processes  may  be  watched  under  the  microscope.  The  intestine  of  an 
etherised  or  curarised  frog  is  drawn  out  through  an  opening  made  in 
the  side  of  the  abdominal  wall,  and  the  mesentery  is  spread  out  on  a 
slide  beneath  a  microscope.  In  this  way  the  mesentery,  with  its  ves- 
sels, is  subjected  to  the  influence  of  the  air  and  the  irritating  substances 
in  it.  After  a  short  interval  an  inflammation  begins,  all  the  various 
manifestations  of  which  can  be  observed  from  beginning  to  end,  and 
all  the  more  exactly  if  the  preparation  is  protected  from  all  bruising, 
drying,  or  soiling,  etc.  The  webbing  between  the  toes  or  the  tongue 
of  the  frog  can  be  used  in  the  same  manner :  the  tongue  is  drawn  out 
and  fastened  with  insect  pins  to  a  cork  rim  around  a  slide,  and  then 
by  cauterising  or  scratching  the  papillse  an  inflammation  can  be  pro- 
duced and  the  various  phenomena  studied. 

There  is  first  seen  a  dilatation  of  the  exposed  vessels  of  the  mesen- 
tery, if  that  is  employed,  beginning  in  the  arteries  and  extending  to 
the  veins,  and  to  a  less  extent 
involving  the  capillaries. 
Simultaneously  with  the  dil- 
atation of  the  vessels  the 
blood  stream  l)egins  to  flow 
more  rapidly,  and  this  is 
followed  sooner  or  later,  in 
from  half  an  hour  to  an 
hour,  by  a  marked  slowing 
of  the  current.  As  a  result 
of  this  slowing  the  separate 
corpuscles  can  be  distin- 
guished in  the  veins  and  cap- 
illaries, and  even  in  the 
arteries ;  and  they  will  be 
found  to  accumulate,  espe- 
cially in  the  veins  and  cap- 
illaries. In  the  veins,  par- 
ticularly, there  will  be  large 
numbers  of  colourless  blood- 
corpuscles  in  the  peripheral  portions  of  the  current,  and  occasionally 
they  will  stick  to  the  inner  walls  of  the  veins  (peripheral  stasis  of  the 


Fig.  219. — Inflamed  mesentery  of  a  frog  ;  F,  vein  ;  A, 
small  artery  and  capillaries.  The  vessels  contain 
white  blood  corpuscles  on  their  inner  walls,  some 
beiniT  in  the  process  of  emigration;  the  surround- 
inii'  tissues  contain  numerous  leucocytes  which  have 
already  emigrated  from  the  vessels. 


234: 


INFLAMMATION  AND   INJURIES. 


white  corpuscles  or  leucocytes,  Fig.  219).  The  red  cells,  on  the  con- 
trary, continue  to  flow  along  with  diminished  rapidity  in  the  centre  of 
the  stream.  Presently,  following  the  peripheral  stasis  of  the  white 
cells,  there  will  be  observed  a  new  phenomenon  :  a  point  will  be  seen 
to  project  from  the  external  contour  of  some  vein  or  capillary,  and 
then  gradually  become  larger  and  more  and  more  prominent  (Fig. 
220,  a) ;  and  Anally  this  bit  of  protoplasm  will  only  remain  attached 
to  the  wall  of  the  vessel  by  one  or  more  processes,  and  at  last  becomes 
entirely  separated,  which  means  that  a  white  corpuscle  has  made  its 
way  out  of  the  vein  or  capillary  (Fig.  220,  &).  Six  or  eight  hours  later 
this  process  has  continued  to  such  an  extent  that  the  veins  and  capilla- 
ries are  surrounded  by  these  migrated 
white  cells.  In  addition  to  these  cells, 
which  are  usually  polynuclear,  there  will 
be  found  small  round  mononuclear  cells 
(lymphocytes),  which,  according  to  Grawitz 
and  Ribbert,  are  to  be  regarded  as  derived 
from  the  fixed  connective  tissue  cells, 
though  Baumgarten  claims  that  they  are 
likewise  white  corpuscles  which  have  mi- 
grated from  the  vessels  of  the  same  region 
(leucocytes).  According  to  Baumgarten, 
the  small  mononucleated  lymphocyte  form 
of  leucocyte  is  the  predominant  element 
in  chronic  inflammations.  AValler  was  the 
first  (1846)  to  note  the  migration  of  the 
leucocytes  from  the  interior  of  the  vessels, 
but  his  observations  had  been  entirely  for- 
gotten when  Cohnheim  rediscovered  this 
phenomenon  in  1867. 
Hed  blood  disks  also  pass  through  the  walls  of  the  capillaries,  but 
not  of  the  veins,  for  in  the  capillaries  both  classes  of  cells  come  in  con- 
tact with  the  walls,  and  are  not,  as  in  the  veins,  confined  to  separate 
parts  of  the  blood  current.  The  proportion  of  red  cells  contained  in 
the  exudate  varies ;  some  lie  here  and  there  on  the  outer  wall  of  the 
capillaries,  some  collect  in  tiny  punctate  haemorrhages,  and  some  are 
washed  away  in  the  stream  of  transuded  serum.  No  blood-corpuscles 
migrate  through  the  walls  of  the  arteries. 

The  time  required  for  a  wdiite  cell  to  pass  through  the  wall  of  a 
capillary  or  vein  varies,  and  the  same  holds  true  as  to  the  passage 
(diapedesis)  of  a  red  cell  tlirongh  the  wall  of  a  capillary.  Sometimes 
the  movement  is  slow,  while  at  others  a  few  minutes  are  enough  for 


Fig.  220. — Emicrration  of  leucocytes 
a,  Incomplete,  h.  complete  emi 
gration  i. schematic;. 


§56.]  INPLAMMATIOX.  235 

three,  four,  or  more  cells  to  escape  one  after  the  other  at  the  same 
spot;  and  iinniediately  thereafter  the  hlood  stream,  with  its  corpuscles, 
tiows  on  normally  ])ast  tiie  point  where  they  have  esca})ed. 

Significance  of  the  escape  of  the  Leucocytes. — As  Leber  has  demon- 
strated, tlie  escape  of  the  leucocytes  from  the  vessels  is  not  unreo;u- 
lated,  but  they  obey  an  attraction  towards  the  i)lace  of  irritation  similar 
to  that  observed  by  Pfeffer,  O.  Ilertwig  and  Engelmann  in  vegetable 
cells  and  bacteria  upon  which  certain  chemical  substances  exert  a 
peculiar  power  of  attraction  (chemotaxis).  The  substances  which  act 
in  this  manner  on  bacteria  are  the  salts  of  potassium,  peptones,  and 
especial!}'  all  nutritive  substances  ;  while  other  substances,  such  as  free 
acids  and  alkalies  or  alcohol,  have  a  repellent  power  (negative  chemo- 
taxis). These  facts,  which  Pfeffer  has  demonstrated  experimentally 
for  the  fungi,  have  a  most  important  bearing  upon  the  subject  of  in- 
flammation. This  power  to  attract,  or  chemotaxis,  influences  or  even 
controls  the  movements  of  the  leucocytes  in  the  tissues  towards  the 
focus  of  inflammation,  also  the  actual  migration  of  the  cells  from  the 
vessels  and  later  the  formation  of  new  vessels  at  the  same  point.  The 
leucocytes  are  especially  attracted  by  the  bacteria,  or  rather  by  the 
products  of  their  metabolism.  According  to  Buchner,  the  protoplasm 
of  bacterial  cells  contains  substances  which  exert  this  attraction  upon 
the  leucocytes,  the  so-called  bacterial  proteins  which  Nencki  studied 
as  early  as  1880  in  certain  kinds  of  bacteria,  from  a  purely  chemical 
standpoint.  These  proteins  will  produce  inflannnation  or  suppuration 
only  after  they  have  become  separated  from  the  bacterial  cell,  con- 
sequently only  after  the  latter  has  died  or  become  diseased.  The  as- 
sembling of  cells  at  the  seat  of  inflammation  is  to  be  regarded  as 
essentially  a  protective  measure  taken  by  the  orgaiiism  for  the  purpose 
of  defending  itself  against  external  noxious  inlluences.  The  leucocytes 
serve,  perhaps,  to  eliminate,  to  liquefy,  and  to  separate  the  inflam- 
matory focus  from  the  healthy  living  tissues  (Leber). 

Increased  Exudation. — Accompanying  the  migration  or  extravasa- 
tion of  blood-cells  there  is  an  increased  transudation  of  the  liquid 
elements  which  infiltrate  all  the  surrounding  tissues.  This  increases 
the  amount  of  the  lymph  current  until  the  lymph  channels  become 
inadequate  for  carrying  away  the  transuded  liquid,  and  then  results  a 
swelling  of  the  part  of  the  body  which  is  inflamed.  Partly  as  a  result 
of  their  own  power  of  locomotion,  and  partly  carried  along  by  the 
transuded  fluid,  the  white  blood-corpuscles  become  distributed  through 
the  tissues  at  ever-increasing  distances  from  the  vessels  out  of  which 
they  have  wandered.  Finally,  both  the  corpuscles  and  the  exudate 
make  their  way  to  the  surface  of  the  mesentery,  and  there  the  exudate 


236  INFLAMMATION   AND   INJURIES. 

coagulates,  forming  a  so-called  false  membrane,  which  is  filled  with 
numberless  white  blood-corpuscles  and  a  few  red  ones. 

Corresponding  to  the  great  number  of  leucocytes  which  it  contains, 
the  inflammatory  exudate  is  very  rich  in  albumen,  while  the  exudate 
which  follows  passive  congestion  is  not  (Iloppe-Seyler,  Lassar).  Only 
in  cases  of  mild  inflammation,  or  in  the  early  stages  of  others,  does  the 
exudate  contain  a  small  number  of  cells. 

According  to  the  character  of  the  inflammatory  exudate,  we  dis- 
tinguish it  as  serous,  fibrinous,  [croupous,  diphtheritic,  suppurative, 
hsemorrhagic,  and  ichorous.   /'■    •      -'■-'•' 

Proliferation  of  Connective-tissue  Cells  in  Inflammation. — Not  all  of 
the  cells  which  are  found  in  inflamed  parts  are  migrated  leucocytes. 
The  fixed  connective-tissue  cells  proliferate  by  rapid  division,  and  con- 
tribute notably  to  the  cellular  infiltration  of  the  inflammatory  focus. 

According  to  Strieker  and  Grawitz,  the  intercellular  substance  of 
the  tissues  undergoes  a  cellular  metamorphosis  when  inflamed,  revert- 
ing to  its  embryonic  cellular  state.  The  cells  also  which  have  hitherto 
lain  dormant  in  the  stroma  (dormant  cells,  Grawitz)  are  said  to  awake 
to  renewed  activity.  The  views  which  Grawitz  has  expressed  con- 
cerning the  process  of  inflammation  are  of  great  scientific  interest,  but 
they  greatly  lack  the  support  of  observed  facts,  and  have  not  yet  met 
with  general  acceptance. 

Inflammation  from  Croton  Oil. — The  manifestations  of  inflammation  just 
described  can  also  be  produced  by  irritating  the  frog's  tongue  with  very  dilute 
croton  oil  (I'bO  of  olive  oil),  bj'  cauterising  it  with  a  stick  of  nitrate  of  silver, 
or  by  applying  a  ligature  to  temporarily  shut  off  the  blood  from  the  vessels 
of  the  tongue.  Precisely  similar  phenomena  can  be  observed  in  warm- 
blooded animals — for  instance,  in  the  mesentery  of  a  small  rabbit.  All  the 
gross  changes  which  take  place  in  an  inflammation  can  be  produced  in  a 
rabbit's  ear  by  painting  it  with  croton  oil,  cauterising  it,  applying  a  ligature, 
or  by  subjecting  it  to  heat  or  cold,  as  by  dipping  it  in  hot  water  or  lightly 
freezing  it  with  a  cooling  mixture.  An  ear  which  has  been  subjected  for 
even  a  few  minutes  to  a  tempei^ature  of  56°  to  60°  C.  (140°  to  147°  F.),  or 
—18°  to  —20°  C.  (—1°  to  —4°  F.),  will  inevitably  necrose.  After  a  rabbit's  ear 
has  recovered  from  the  eti'ects  of  croton  oil,  it  gains,  according  to  Samuel, 
a  kind  of  immunity  as  regards  this  drug — i.  e.,  it  reacts  to  a  subsequent  appli- 
cation of  the  oil  much  less  violently  than  an  ear  which  has  not  been  so  treated. 

-^i*>.  The  phenomena  thus  described — viz.,  the  simple  congestive  hyper- 
aemia,  the  extravasation  of  the  corpuscular  elements  from  the  capilla- 
ries and  veins,  the  increased  exudation  terminating  in  stasis  and  later 
in  death  of  tissue,  and  also  the  proliferation  of  the  fixed  connective- 
tissue  cells — form  a  group  of  symptoms  which  we  are  accustomed  to 
designate  by  the  name  of  inflammation. 


§56]  INFLAMMATION.  237 

Cause  of  Inflammation. — Colinlieim  ascribed  the  cause  of  all  these 
plienoinena  and  tlic  essence  of  iiitiainrnation  to  niolecnlar  changes  in 
the  walls  of  the  vessels.  According  to  him,  these  molecular  changes 
increase  the  adhesiveness,  and  consequently  the  friction,  between  the 
blood  and  the  walls  ;  hence  the  slowing  of  the  stream.  Exactly  what 
kind  of  a  change  is  produced  in  the  vessel  walls  in  inflammation  is  not 
clearly  understood ;  it  cannot  be  detected  with  the  microscope,  and  we 
can  only  say  that  the  walls  become  more  pervious,  enough  so  to  occa- 
sion the  increase  in  exudation  notwithstanding  the  diminution  of  the 
blood  pressure  which  takes  place  especially  in  the  capillaries.  Wini- 
warter has  shown  that  a  colloid  liquid,  such  as  a  solution  of  glue,  can 
pass  through  the  inflamed  walls  of  blood-vessels  even  when  the  pres- 
sure is  subnormal.  A  ru])ture,  an  interruption  of  continuity  in  the  wall 
of  the  vessel,  permitting  the  escape  of  the  leucocytes  and  of  a  few  red 
corpuscles,  certainly  does  not  take  place.  Likewise,  Arnold's  theory 
that  in  inflammation  the  natural  stomata  between  the  endothelial  cells 
become  enlarged  and  that  new  ones  form,  is,  as  Cohnheim  always  main- 
tained, incorrect.  Cohnheim's  com])arison  of  inflammatory  exudation 
with  filtration  seems  very  appropriate.  Under  normal  conditions  only 
a  small  amount  of  a  thin  liquid  can  pass  through  the  filter  of  the  vessel 
wall ;  but  when  inflammation  sets  in  the  filter  becomes  coarser  and 
permits  not  only  denser  solutions  to  pass  through,  but  also  formed  ele- 
ments, the  blood-corpuscles.  The  change  produced  in  the  vessel  wall 
by  inflammation  is,  according  to  Cohnheim,  probably  chemical. 

But  all  the  manifestations  of  inflammation  cannot  be  explained 
by  the  condition  of  the  vessel  walls,  which  Cohnheim  thought  was 
sufficient.  The  investigations  recently  made  by  Recklinghausen, 
Arnold  and  others  go  to  show  that  Cohnheim's  theory  needs  certain 
limitations  in  view  of  the  fact  that  a  distinction  must  be  made  between 
the  exudation  of  fluid  constituents  of  the  blood  and  the  emigration  of 
white  corpuscles.  Thoma's  researches  have  shown  that  a  primary 
alteration  in  the  walls  of  the  vessels  is  not  always  the  cause  of  the  emi- 
gration. A  simple  disturbance  of  circulation  following  an  irritation 
of  the  local  vasomotor  centres  produces  a  peripheral  stasis  and  an 
emigration  of  leucocytes.  But  the  latter  phenomenon  will  only  last 
a  brief  time  in  those  cases  in  which  there  is  no  other  influence  at  work  ; 
the  vasomotor  nerves  resume  their  function,  and  the  peripheral  slow- 
ing of  the  current  and  the  escape  of  the  leucocytes  cease.  If  the  dis- 
turbances in  innervation  are  more  marked,  and  if  the  emigration  is 
allowed  to  go  on  for  a  longer  time,  a  secondary  change  in  the  walls  of 
the  vessels  takes  place.  But  in  these  cases  the  disturbance  in  the 
innervation    of  the  vessels  is   the    primary  event,  and  not  the  alter- 


238  INFLAMMATION    AND   INJURIES. 

ation  in  tlieir  walls.  Tlin>  Tveekliiigliausen  seems  to  be  correct 
in  ascribing  to  the  vasomotor  nerves,  and  particularly  to  their  ter- 
minal local  centres,  an  important  part  in  the  inflammatory  process, 
and  especially  in  the  emigration  of  the  leucocytes.  Herpes  zoster  and 
other  diseases  resulting  from  disturbances  in  innervation  go  to  prove 
the  truth  of  this  theory.  Samuel  has  shown  that  the  inflammatory 
process  becomes  more  severe  when  there  is  vasomotor  paralysis. 
Moreover,  the  emigration  of  leucocytes  is  affected  in  both  a  positive 
and  negative  way  by  the  above-mentioned  chemotaxis.  On  the  other 
hand,  the  exudation  of  the  fluid  elements  of  the  blood  during  an  in- 
flammation can  only  be  explained  by  a  change  in  the  permeability  of 
the  walls  of  the  vessels,  located  in  either  the  endothelial  cells  or  the 
cement  sul)stance  between  them. 
,-\f:'  According  then,  to  our  present  knowledge,  we  must  look  for 
an  explanation  of  the  phenomena  of  inflammation  (1)  in  vasomotor 
changes  in  the  vessels,  or,  rather,  in  disturbances  within  the  vasomotor 
centres  in  the  walls  of  the  vessels ;  (2)  in  an  increased  permeability  of 
these  walls;  (3)  in  the  positive  (attracting)  and  negative  (repelling) 
chemotaxis  of  tlie  inflammatory  focus,  and  Anally  (4)  in  the  reactionary 
proliferation  of  the  cells  in  the  inflamed  tissues.  It  is  an  exceedingly 
ditiicult  matter  to  give  an  exhaustive  and  satisfactory  definition  of  in- 
flaminatii)n. 

Other  Theories  of  Inflammation.— Before  Cohnheim,  Recklicghausen,  and 
Thoma  had  established  the  above  explanation  of  inflammation,  a  great  va- 
riety of  theories  had  been  advanced,  the  most  important  being  the  neuro- 
humoral (Culleu,  Henle)  and  the  celkdar  (Yirchow).  According  to  the  for- 
mer, the  nature  of  inflammation  or  the  disturbances  in  the  circulation  are 
explained  either  by  a  contraction  or  dilatation  of  the  afPerent  ai'teries,  pro- 
duced reflexly  through  stimulation  of  the  sensory  nerves.  We  have  seen 
that  nervous  influences  real!)'  do  play  an  active  part  in  the  process  of  inflam- 
mation. 

Virchow's  cellular  theory  of  inflammation  is  based  upon  the  changes  in 
the  life  of  the  cells  brought  about  by  the  primary  causes  of  inflammation. 
Virchow  regarded  the  cells  of  the  tissues  as  the  essential  elements  in  the  in- 
flammatory process.  As  a  result  of  the  inflammatory  irritation  they  were 
caused  to  swell  and  proliferate  and  form  pus  corpuscles.  These  altered  cells 
are  supposed  by  Yirchow  to  exercise  a  kind  of  attractive  power  for  the  con- 
tents of  the  vessels,  producing  increased  exudation. 

Samuel  thinks  that  inflammation  is  due  to  a  changed  relationship  of  the 
blood,  the  walls  of  the  vessels,  and  the  tissues  to  each  other.  ReckHnghau- 
sen  agrees  with  him  in  general. 

Landerer  thinks  that  the  inflammatory  changes  in  the  circulation  depend 
upon  a  disturbance  of  the  normal  balance  between  the  blood  pressure  and  the 
tension  of  the  tissues,  caused  by  a  change  in  the  elastic  properties  of  the  tis- 
sues and  the  walls  of  the  vessels.     This  change  in  elasticity,  he  is  inclined  to 


5i  57.]  INFLAMMATION.  239 

l>elieve,  is  tlio  primary  factor,  though  he  admits  that  the  walls  of  the  vessels 
may  become  primarily  diseased. 

No  one  of  these  theories  can  by  itself  explain  the  nature  of  inllammation, 
especially  if  that  theory  is  based  upon  only  a  single  manifestation  of  the  in- 
flammatory process  and  attempts  to  solve  the  problem  from  this  staudi)oiut 
alone.  Consequently,  it  is  evident  why  Cohnheim's  attempt  to  explain  in- 
flammation by  a  change  in  the  walls  of  the  vessels  is  to-day  regarded  as 
inadequate.  No  value  can  be  attached  to  any  theory  which  does  not  include 
a  correct  explanation  of  the  changes  produced  under  the  stimulus  of  inflam- 
mation in  both  the  solid  and  fluid  elements  of  the  tissues  (cells,  nerves,  and 
walls  of  the  vessels),  and  does  not  consider  these  in  their  causal  relationship 
to  one  aiiother. 

§  5T.  Causes  of  Inflammation. — The  causes  of  iiijiammation  are 
very  numerous.  Any  inlluence  which  produces  a  change  in  the  walls 
of  the  vessels  in  any  particular  part  of  the  body,  in  the  manner  above 
described,  may  give  rise  to  inflammation.  "\Ve  recognise  principally 
the  following  classes  of  inflammation  which  differ  in  point  of  etiology  : 

1.  Inflammation  from  mechanical  causes  (every  kind  of  trau- 
matism). 

2.  Inflammation  following  the  action  of  extremes  of  temperature 
(tliermal  inflammation  ;  burning,  freezing). 

3.  Inflammation  due  to  chemical  causes  (toxic  bacterial  infection). 
Under  the  heading  of  toxic  inflammations  belong  not  only  those 

which  are  produced  by  the  action  of  some  particular  chemical  such  as 
mercury,  sulphuric  acid,  etc.,  but  it  includes  all  inflammations  caused 
by  the  absorption  of  chemically  changed,  decomposed,  or  putrid  sub- 
stances of  a  gaseous  or  liquid  nature.  Inflammations  following  the 
stings  of  insects,  such  as  bees,  and  those  from  the  bites  of  serpents,  all 
come  within  the  class  of  toxic  inflammations.  Advancing  a  step  fur- 
ther, we  come  to  the  infectious  inflammations,  or  .those  which  are  pro- 
duced by  the  ingress  of  a  low  order  of  organism  or  fungi — for  exam- 
])le,  after  an  injury  to  the  tissues  from  some  traumatism. 

Significance  of  Micro-organisms. — Micro-organisms^  especially  the 
fungi  schizomycetes  or  bacteria,  are  the  worst  enemies  of  the  surgeon, 
interfering  with  the  normal  healing  process  of  a  wound  and  causing  the 
secondary  wound  diseases.  Hallier,  Pasteur,  Billroth,  Klebs,  Eberth, 
and  particularly  Robert  Koch  and  his  followers,  have  made  great  ad- 
vances in  the  study  of  micro-organisms.  The  honour  of  having  estab- 
lished the  etiology  of  parasitic  infectious  diseases  by  means  of  new 
methods  of  investigation  belongs  chiefly  to  Robert  Koch.  At  the  time 
when  Lister  established  his  antiseptic  and  aseptic  methods  of  oper- 
ating on  the  principle  that  all  infection  was  due  to  bacteria,  which, 
though  not  then  proved,  nevertheless  seemed  probable,  surgery  made 


240  INFLAMMATION  AND  INJURIES. 

the  greatest  advance  in  its  liistory.  Every  inflammatory  process  in  a 
wound,  especially  all  suppuration,  is  due  principally  to  the  presence  of 
micro-organisms,  while  the  injury  itself  plays  only  a  subordinate  part. 

Causes  of  Acute  Suppurative  Inflammation— Significance  of  Bacteria.— The 

investigations  of  Ogston,  Strauss,  etc.,  prove  that  chemical  irritants,  no  matter 
of  what  kind,  do  not  excite  suppurative  inflammation,  hut  that  the  latter  can 
only  be  caused  hy  mici'o-organisms.  These  authorities  performed  their  ex- 
periments with  the  most  rigid  antiseptic  precautions.  Strauss,  for  example, 
to  prevent  accidental  infection  from  the  wound,  made  an  eschar  over  the 
selected  area  of  skin  with  the  Pacquelin,  then  through  this  made  his  incision 
with  a  red-hot  knife,  and  introduced  the  long  tip  of  a  glass  tube  containing 
the  sterilised  fluid  into  the  subcutaneous  cellular  tissue,  the  upper  end  of  the 
tube  meanwhile  being  closed  with  a  cotton  plug.  The  glass  tip  was  then 
broken  off  beneath  the  skin,  and  the  fluid  was  forced  out  of  the  tube  and 
under  the  skin  by  blowing  with  the  mouth  over  the  cotton  plug.  After  tak- 
ing away  the  tube  the  injured  ai'ea  of  skin  was  again  cauterised.  After  the 
introduction  in  this  manner  of  such  chemical  irritants  as  sulphuric  acid,  tur- 
pentine, croton  oil,  mercury,  etc.,  only  a  serous,  sei'O-fibrinous,  or  fibrino- 
dipbtheritic  inflammation  resulted,  but  never  acute  suppuration.  If  acute 
suppuration  did  occur,  it  was  al  ways  possible  to  demonstrate  the  presence  of 
micro-organisms.  These  authorities  experimented  on  rabbits,  in  which,  to  be 
sure,  a  supnurative  inflammation  is  seldom  caused  by  chemical  irritation. 

But  it  has  recently  been  iiroved  that  these  statements  are  incorrect.  Orth- 
maun,  Grawitz,  and  De  Barry  have  demonstrated  that  sterilised  chemical  sub- 
stances, such  as  nitrate  of  silver,  oil  of  turpentine,  liq.  amraonii  caustici,  digi- 
toxin,  etc.,  can  produce  acute  suppuration  in  the  subcutaneous  tissue  ;  and 
according  to  Scheuerlen  and  Grawitz.  sterilised  cultures  of  various  micro- 
organisms— in  other  Avords,  products  of  bacterial  metabolism,  such  as  putres- 
cin,  cadaverin,  penthamethylendiamin,  etc. — act  in  the  same  way.  A  similar 
conclusion  has  been  reached  by  Krynski,  who  experimented  on  dogs  and  rab- 
bits with  the  greatest  care,  parti \'  by  Strauss's  and  partly  by  Councilman's 
methods,  using  germ-free  (aseptic)  chemical  substances,  the  microbes  which 
cause  suppuration  and*  the  products  of  their  metabolism.  Krynski  asserts,  in 
opposition  to  Strauss  and  others,  but  agreeing  with  Brewing  and  Dubler.  that 
oil  of  turpentine  or  mercury  produces  in  dogs  and  rabbits  a  suppuration  which 
is  free  from  bacteria.  A  one-to-five-per  cent,  solution  of  nitrate  of  silver  ex- 
cites the  formation  of  pus  in  dogs,  but  only  an  inflammatory  oedema  in  rab- 
bits. Croton  oil,  bromine,  mineral  acids  (hydrochloric,  sulphuric,  nitric,  and 
chromic),  organic  acids  (acetic,  carbolic,  lactic,  etc.)  do  not  cause  pus.  In 
dogs  it  is  produced  by  creolin  and  petroleum.  Clean,  mechanically  acting 
agents,  si;ch  as  glass  splinters,  do  not  excite  pus  formation.  The  bacteria  of 
suppuration  (the  staphylococci  and  streptococci),  according  to  Krynski,  will 
only  excite  the  formation  of  pus  in  tissues  which  have  become  pathologically 
changed,  and  they  will  not  develop  in  healthy  tissues,  but  become  destroyed, 
while  the  bacillus  pyogenes  foetidus  will  excite  suppuration  even  in  perfectly 
healthy  tissue.  Krynski  maintains  that  tlie  pneumococcus  Friedlanderi  and 
the  micrococcus  prodigiosus  are  not  pyogenic :  but  Grawitz  and  Pe  Barry  have 
established  the  latter's  pyogenic  character  in  the  case  of  dogs,  cats,  rabbits,  and 


§58.]  INFLAMMATION,  241 

rats.  Sterilised  cultures  of  the  staphylococci  and  streptococci,  or  the  sterilised 
solutions  of  the  products  of  their  metabolism,  will  produce  pus,  while  steril- 
ised cultures  of  the  prodifi^iosus  and  decomposition  extracts  have  no  such 
power.  Although  there  can  be  no  doubt  as  to  the  possibility  of  exciting-  sup- 
puration in  the  subcutaneous  tissue  of  animals  by  the  experimental  introduc- 
tion of  germ-free  chemical  substances,  yet  it  is  just  as  true  that  suppuration 
in  man  under  ordinary  circumstances  is  caused  by  the  presence  and  activity 
of  micro-organisms,  usually  of  a  specific  variety — viz.,  pyogenic  cocci. 

Immunity  against  Virulent  Staphylococci.— The  investigations  of  Roux, 
Kronacher  and  others  are  of  great  interest  as  regards  the  acquirement  of 
immunity  against  virulent  staphylococci.  By  the  inoculation  of  sterilised 
cultures  of  the  staphylococcus  pyogenes  aureus  white  mice  can  be  made  un- 
susceptible to  cultures  containing  virulent  cocci. 

Boucliard,  Gley  and  others  have  shown  that  the  injection  of  the  soluble 
products  of  certain  micro-organisms  such  as  the  bacillus  pyocyaneus  has  an 
antiphlogistic  efifect  from  paralysis  of  the  vasodilator  nerves,  which  prevents 
dilatation  of  the  vessels  and  emigration  of  the  leucocytes. 

Leber's  Phlogosin— Buchner's  Bacterial  Protein.— Leber's  investigations 
are  extremely  iuterepting.'*'  He  showed  that  the  micro-organisms,  in  virtue 
of  the  diffusible  products  of  their  metabolism,  can  excite  an  inflammatory 
reaction  at  a  distant  part  of  the  body,  and  from  liquids  containing  staiDhylo- 
cocci  he  isolated  a  crystallisable  body,  phlogosin,  capable  of  producing  in- 
tense inflammatory  and  necrotic  processes.  Buchner  demonstrated  that  the 
protoplasmic  contents  of  the  bacterial  cells,  the  so-called  bacterial  protein,  has 
a  similar  power  of  exciting  inflammation  and  suppuration  when  separated 
from  the  bacterial  cells — in  other  words,  when  these  die  or  become  diseased. 
Buchner  has  so  far  isolated  this  protein  from  seven  kinds  of  bacteria,  and 
proved  its  jiyogenic  action. 

Inflammatory  Leucocytosis. — After  invasion  of  the  blood-vessels  with 
the  fungi  of  suppuration  there  is  an  increase  in  the  number  of  leucocytes  in 
the  blood  (inflammatory  leucocytosis),  originating  In  the  spleen,  the  lymph 
glands,  and  bone  marrow.  According  to  Limbeck,  this  is  not  so  much  a  new 
formation  of  leucocji;es  as  a  result  of  the  flushing  out  of  the  above  organs. 
This  inflammatory  leucocytosis  has  an  intimate  connection  with  the  exuda- 
tion accompanying  inflammation,  and  with  the  peptonuria  (Leber,  Hof- 
meister,  Maixner,  etc.). 

As  to  the  influence  of  micro-organisins  upon  the  production  of 
"wouud  diseases,  etc.,  we  shall  see  later  (§  66)  tliat  each  separate  wound 
disease  is  caused  by  a  particular  and  clearly  distinguishable  micro- 
organism. A  short  review  of  the  morphology  and  general  significance 
of  these  will  be  found  in  ^  59. 

§  58.  Sjnnptoms,  Diagnosis,  and  Treatment  of  Inflammation. — The 
symptoms  of  inflammation — redness,  swelling,  increased  warmth,  and 
pain — are  easily  explained  by  the  disturbances  of  circulation  which 
have  been  described.    The  redness  and  increased  warmth  are  due  to  the 

*  Fortschritte  der  Med.,  1888,  No.  12. 
17 


242  INFLAMMATION   AND   INJURIES. 

distention  of  the  blood-vessels ;  the  swelling  is  likewise  the  result  of 
this,  and  also  of  increased  exudation.  The  pain  is  caused  by  the  pres- 
sure of  the  over-filled  vessels  and  of  the  exuded  fluid  upon  the  sensory 
nerves.  A  fifth  svmptom  is  the  disturbance  of  function,  and  is  pro- 
duced by  the  change  in  the  circtilation  and  the  pressure  of  the  exuded 
fluid  upon  the  motor  nerves,  and  upon  those  governing  secretion,  or 
upon  the  cells  themselves.  The  separate  symptoms  naturally  vary  con- 
siderably in  intensity,  depending  upon  the  severity  of  the  inflammation, 
and  particularly  upon  its  location. 

The  pain  in  inflammation  depends  upon  the  richness  of  the  sensory 
nerve  supply  in  the  inflamed  part,  and  upon  the  amount  of  the  exu- 
date, or  rather  of  the  pressure  which  the  exudate  produces  on  the  sen- 
sorv  nerves.  Furthermore,  the  amount  of  expansion  that  the  inflamed 
part  is  capable  of  is  an  important  factor.  For  all  these  reasons,  an 
acute  inflammation  located  under  the  fascia,  or  in  the  tips  of  the  fingers, 
under  the  nails,  is  particularly  painful,  while  one  involving  mucous 
membrane  is  much  less  so. 

The  increased  warmth  is  the  result  of  an  increased  amount  of  blood. 
As  Cohnheim  has  shown,  nearly  double  the  normal  amount  of  blood 
flows  through  a  dog's  paw  when  inflamed.  There  is  an  increased 
amount  of  warmth  brought  to  the  part,  but  the  diminished  rapidity  of 
the  current  causes  an  increase  in  the  loss  of  heat  by  radiation.  There 
has  been  an  erroneous  belief  that  the  inflammatory  focus  was  in  itself 
productive  of  heat,  and  that  the  temperature  at  this  point  was  higher 
than  the  general  body  temperature.  But  ordinarily  it  is  certain  that 
the  temperature  of  the  inflamed  spot  never  exceeds  that  of  the  blood, 
and  generally  is  not  as  high.  Hunters  law  still  holds  true  to  this  day 
— viz.,  that  the  local  temj^erature  of  an  inflamed  part  cannot  rise  above 
that  at  the  source  of  the  circulation,  the  heart.  The  redness  is  usually 
dependent  upon  the  richness  in  blood  supply  of  the  inflamed  tissues. 
The  swelling  or  inflammatory  tumefaction  resulting  from  the  exuda. 
tion  which  takes  place  varies,  of  course,  with  the  anatomical  structure 
of  the  inflamed  region.  In  general,  the  exudation  takes  place  in  the 
same  way.  but  it  may  manifest  itself  in  many  different  ways,  depend- 
ing upon  whether  it  occurs  in  firm  tissues  like  bone  or  cartilage,  or 
in  wide-meshed  connective  tissue,  or  in  a  glandular  organ,  or  in  a  cav- 
ity, snch  as  the  pleural  cavity. 

As  regards  the  location  of  the  inflammation,  we  distinguish  between 
a  superficial  and  a  deep  or  parenchymatous  inflammation  in  the  interior 
of  an  organ.  To  the  superficial  inflammations  Ijelong  those  situated  in 
the  superficial  portions  of  the  body,  in  the  mucous  membranes,  or  the 
surfaces  of  the  great  serous  cavities.     In  a  superficial  inflammation  the 


§58.]  INFLAMMATION.  243 

inflammatory  exudate  appears  superficially,  a^d  forms  an  exudate  in 
the  narrow  sense,  while  in  a  parenchymatous  inflammation  the  exudate 
is  spread  out  in  the  tissue  in  (juestion  in  the  form  of  a  so-called  infiltra- 
tion. For  distinguishing  the  location  of  the  parenchymatous  inflam- 
mations more  exactly — as,  for  example,  those  which  occur  in  the  glands 
or  muscles — a  distinction  is  made  between  a  parenchymatous  inflamma- 
tion in  its  narrow  sense  and  an  interstitial  inflammation,  according  as 
the  inflammatory  process  affects  more  the  gland  cells,  such  as  those 
making  up  tlie  parenchyma  of  the  liver,  or  the  connective-tissue  stroma. 

The  Varying  Constitution  of  the  Inflammatory  Exudate. — The  com- 
position of  the  exudate  is  of  the  greatest  importance  in  determining  the 
cliaracter  of  the  inflammation.  '  If  the  latter  belongs  to  the  lower  grades 
of  the  process,  or  if,  in  other  words,  there  is  but  a  slight  change  in 
the  walls  of  the  vessels,  the  exudate  is  serous — that  is,  there  is  only  a 
small  amount  of  albumen  and  formed  elements  (blood-corpuscles)  con- 
tained in  it.  On  the  other  hand,  we  speak  of  a  fibrinous  or  croupous 
inflammation  when  the  exudate  is  rich  in  spontaneously  coagulating  albu- 
men and  in  white  blood-corpuscles.  In  a  fibrinous  inflammation  the 
diseased  part,  such  as,  for  instance,  the  serous  membrane  or  the  inner 
surface  of  a  joint  capsule,  becomes  covered  with  a  more  or  less  thick 
layer  of  soft  fibrin,  which  gives  it  sometimes  a  smooth  and  sometimes 
a  shaggy  appearance.  The  microscopic  examination  of  such  a  fibrin- 
ous pseudo-membrane  reveals  the  presence  of  an  immense  number  of 
white  blood-corpuscles  scattered  amongst  threads  of  fibrin  and  granular 
matter.  This  same  croupous  or  fibrinous  covering  is  found  on  the  sur- 
faces of  mucous  membranes.  Between  the  two  main  types  of  serous 
and  fibrinous  inflammations  there  are,  of  course,  a  number  of  interme- 
diate forms  which  are  designated  as  sero-fibrinous  exudates. 

Suppurative  Exudate. — The  third  kind  of  exudate  is  the  suppura- 
tive or  purulent,  consisting  of  a  thick,  milky  or  cream-like,  non-coagu- 
lable  fluid,  generally  without  odour,  and  briefly  designated  by  the  name 
of  pus.  Microscopically,  this  is  a  colourless  fluid  containing  a  vast  quan- 
tity of  cells,  "  pus-cells,"  and  a  few  i"ed  blood-corpuscles.  According 
to  Grawitz,  the  suppurative  inflammation  is  only  a  more  advanced 
grade  of  inflammation,  while  Weigert,  on  the  other  hand,  maintains 
that  it  represents  qualitatively  a  particular  kind.  Strieker  and  Reck- 
linghausen think  that  suppuration  is  not  exclusively  a  melting-down 
process  of  the  tissues  without  coagulation,  produced  by  means  of  emi- 
grated leucocytes,  but  rather  that  a  proliferation  of  the  fixed  connec- 
tive-tissue elements  also  plays  an  important  part.  By  the  proliferation 
of  the  fixed  cells  a  large  number  of  young  cells  are  formed  which  cor- 
respond in  appearance  to  the  mononuclear  white  blood-corpuscles. 


244:  INFLAMMATION  AND   INJURIES. 

Pus  is  a  product  composed  of  emigrated  leucocytes  and  the  altered 
offspring  of  the  connective-tissue  cells.  Every  suppurative  inflamma- 
tion is  to  be  considered  as  a  severe  inflammation,  and,  as  we  have  indi- 
cated, it  is  in  the  main  of  an  infectious  nature — that  is,  it  is  the  result 
of  an  infection  by  bacteria.  But  we  have  seen  that  sometimes  even 
germ-free  chemical  substances  may  produce  suppuration  (Grawitz,  De 
Barry,  Krynski,  etc.). 

Between  the  extreme  types  of  purulent  and  fibrinous  inflammation 
there  are  also  many  intermediate  gradations  of  the  process  which  are 
known  as  fibrino-purulent  inflammations.  If  the  suppurative  process 
is  sharply  defined  in  the  tissues,  there  results  what  is  called  an  abscess ; 
but  if  the  process  is  more  diffuse,  it  is  spoken  of  as  suppurative  infil- 
tration. An  abscess — i.  e.,  a  cavity  filled  with  pus — results  from  a  sup- 
purative infiltration  which  liquefies  and  dissolves  the  affected  tissues. 
A  loss  of  substance  in  the  superficial  portions  of  the  bod}',  accom- 
panied by  the  formation  of  pus  and  breaking  down  of  the  granulation 
tissue,  constitutes  an  ulcer.  A  collection  of  pus  in  a  cavity  is  called  a 
purulent  effusion,  while  a  purulent  secretion  from  a  mucous  membrane 
is  called  a  purulent  catarrh. 

Hsemorrhagic  Exudate. — The  fourth  kind  of  exudate  is  the  haemor- 
rhagic — i.  e.,  the  serous,  fibrinous,  or  purulent  exudate  contains  such 
an  amount  of  red  blood-corpuscles  that  it  becomes  red  in  colour.  The 
hsemorrhagic  exudate  is  a  symptom  of  serious  alterations  in  the  walls 
of  the  capillaries,  such  as  takes  place  in  certain  constitutional  diseases, 
or  as  the  result  of  a  systemic  infection  through  bacteria. 

Ichorous  Exudate. — The  decomposed,  foul-smelling  exudate  accom- 
panying putrefaction  is  designated  as  ichorous  or  putrid.  It  has  a 
grey  or  greyish-green,  brown,  or  dirty  yellow  colour. 

Croupous  or  Diphtheritic  Inflammation. — The  so-called  croupous  or 
diphtheritic  inflammation,  or  the  croupous  or  diphtheritic  exudate,  is 
the  result  of  the  combination  of  an  inflammatory  process  wuth  another 
of  a  different  nature.  Croupous  inflammation  of  a  mucous  membrane  is 
characterised  by  the  formation  of  a  skin-like,  fibrinous  exudate  (croup- 
ous membrane)  clinging  to  its  surface  and  taking  the  place  of  the  origi- 
nal epithelial  covering  which  has  perished.  This  croupous  membrane 
consists  of  a  network  of  fibrin  fibres  containing  leucocytes  and  the  re- 
mains of  the  epithelium.  In  diphtheria  the  death  of  tissue  extends 
deeper,  and  the  process  is  a  combination  of  necrosis  and  fibi-inous  in- 
flammation. The  affected  portion  of  the  mucous  membrane  is  changed 
into  a  peculiar  greyish-white,  tough  mass,  which  comes  away  in  mem- 
brane-like layers  (diphtheritic  pseudo-membrane),  and  produces  corre- 
sponding losses  of  substance   (diphtheritic  ulcers).      The   tissues  de- 


§  58.]  INFLAMMATION.  245 

stroyed  by  the  inflammatory  process  coagulate  in  flaky  or  stringy 
masses,  wliicli  signifles  serious  structural  changes  involving  the  blood- 
vessels and  surrounding  tissue,  with  here  and  there  stasis  and  throm- 
bosis. Cohnheim  and  Weigert  have  given  to  this  form  of  localised 
tissue  death  the  name  of  coagulation  necrosis  (Neumann's  fibrinoid  de- 
generation). "Weigert's  investigations  show  that  coagulation  necrosis  is 
a  death  by  coagulation  of  the  tissue  or  cells  in  a  necrotic  area  through 
which  a  small  amount  of  lymph  flows.  The  lymph,  with  its  fibrinogen, 
penetrates  the  cells  and  coagulates  with  the  fibrino-plastin  within  the 
cells.  Coagulation  necrosis  is  a  frequent  accompaniment  of  inflamma- 
tory processes,  of  embolic  infarcts,  and  of  the  so-called  waxy  degenera- 
tion of  muscles. 

Extension  of  an  Inflammation. — The  inflammatory  process  spreads 
by  infiltration^of  the  connective-tissue  spaces,  the  muscular  sheaths,  and 
the  vascular  channels  with  the  inflammatory  exudate — in  other  words, 
from  a  circumscribed  spot  of  suppuration  (abscess)  there  may  develop 
a  spreading  cellulitis.  The  inflammation  also  spreads  through  the 
lymph  spaces,  the  main  lymphatics,  and  the  blood-vessels.  When  the 
exciting  cause  of  the  inflammation  gets  into  the  circulatory  system, 
the  original  local  disturbance  becomes  a  general  systemic  disease  in- 
volving the  whole  organism.  The  poison — so  to  designate  briefly  the 
noxious  element — passes  through  the  lymph  channels  to  the  nearest 
lymphatic  glands,  exciting  there  also  inflammation,  and  finally  sup- 
puration. These  diseased  glands  then  become  a  fresh  source  of  in- 
flammation, which  in  this  manner  spreads  farther  and  farther  through 
the  body  and  progressively  affects  more  of  its  organs.  Such  a  meta- 
static inflammatory  and  suppurative  process  will  be  again  referred  to 
under  the  heading  of  pyaemia,  by  which  we  mean  a  poisoning  of  the 
blood  by  the  microbes  of  suppuration  and  the  products  of  their  meta- 
bolism. By  the  spreading  of  the  micro-organisms  and  the  products  of 
their  metabolism  throughout  the  circulation,  and  the  production  of  cir- 
cumscribed foci  of  inflammation  in  different  organs,  a  general  systemic 
infection  accompanied  by  fever  results  (see  §  62,  Fever).  We  shall 
learn  later  how  prominently  the  fungi  are  concerned  in  the  extension 
of  the  inflammation  and  in  the  occurrence  of  the  systemic  infection. 
Clinical  observations  and  experiments  on  animals  seem  to  show  that 
local  metastatic  foci  of  suppuration  are  particularly  liable  to  occur 
when  there  exists  a  general  weakness  or  impairment  of  vitality  of  the 
whole  organism  (Rinne).  The  soil  for  the  lodgment  of  the  micro- 
organisms is  made  ready  for  them  in  advance  by  the  products  of  their 
metabolism  which  get  into  the  circulating  blood. 

Duration  of  the  Inflammation. — According  as  the  inflammation  lasts 


246  INFLAMMATION  AND  INJURIES. 

a  shorter  or  longer  time  it  is  sjjokeii  of  as  acute  or  chronic.  The 
manifestations  of  an  acute  inflammation  have  been  sufficiently  de- 
scribed above.  The  acute  inflammation  often  becomes  a  chronic  one, 
or  the  latter  begins  from  the  first  as  such.  The  transition  or  inter- 
mediate types  between  an  acute  and  chronic  inflammation  are  known 
as  subacute  inflammations.  Tubercular  and  syphilitic  inflammations 
are  the  most  important  forms  of  the  chronic  class.  The  true  type  of 
chronic  inflammation  is  the  productive  or  adhesive  inflammation,  which 
leads  to  new  formation  of  tissue,  to  adhesions  and  thickenings  of  every 
description,  depending  upon  the  anatomical  structure  of  the  aflected 
organ,  such  as  a  joint,  bone,  periosteum,  or  connective  tissue.  We 
shall  describe  in  their  proper  place  the  special  symptoms  of  inflamma- 
tions involving  the  different  organs. 

Origin  of  the  Pus-corpuscles.— The  so-called  pus-corpuscles  which  are 
found  in  the  inflammatory  effusion  are  made  up,  iu  part  at  least,  of  the  white 
blood-corpuscles  which  have  wandered  out  from  the  interior  of  the  vessels. 
Whether  all  the  pus-corpuscles  are  emigrated  blood-cells,  or  whether  pus- 
cells  may  originate  otherwise— as,  for  instance,  from  the  fixed  tissue  cells— or 
whether  pus-cells  may  multiply  by  fission  or  division,  are  all  questions  to 
which  various  answers  have  been  given.  Some  have  considered  it  impos- 
sible that  the  enormous  number  of  pus-corpuscles  found  iu  a  large  inflam- 
matory process,  like  a  phlegmon  or  a  large  granulating  wound,  should  all 
be  derived  from  the  blood.  Cohnheim  was  right  in  directing  attention  to 
the  fact  that  the  veins  and  capillaries  contain  comparatively  large  numbers 
of  white  blood-corpuscles,  and  that  the  number  of  these  white  cells  is  much 
increased  during  inflammatory  diseases.  The  white  blood-corpuscles  which 
go  to  form  pus-cells  are  constantly  replaced  by  an  increased  activity  of  the 
spleen  and  lymphatic  glands.  Bottcher,  Strieker  and  his  followers,  Reck- 
linghausen, Grawitz  and  others  differ  from  Cohnheim  in  his  view  that  the 
blood  is  the  sole  source  of  the  pus-cells,  and  affirm  that  the  latter  originate 
in  far  greater  proportion  from  the  fixed  tissue  cells.  These  authors  believe 
that  the  cellular  elements  of  pus  consist  partly  of  emigrated  leucocytes  and 
partly  of  the  offspring  of  the  fixed  connective-tissue  cells.  Grawitz  affirms 
that  the  stroma  or  fibrous  portion  of  the  tissues  takes  on  a  cellular  change 
and  becomes  a  third  source  of  the  pus-corpuscles.  Recklinghausen  has  dem- 
onstrated that  pus-cells,  if  kept  in  a  warm  and  moist  medium  while  being 
examined,  will  change  their  form  and  go  through  the  same  amoeboid  move- 
ments as  the  white  blood-cells. 

Number  of  Pus-cells  in  Pus.— Chelchowski  determined  the  number  of  pus- 
corpuscles  by  means  of  Mai lassey-Ve rick's  apparatus  in  twenty  different 
cases  of  suppuration.  For  diluting  the  pus,  he  employed  a  Aveak  solution  of 
common  salt  or  Toisson's  fluid  (methyl violet).  The  number  of  pus-cells  in 
one  cubic  millimetre  of  pus,  according  to  Chelchowski,  varied  between  four 
hundred  thousand  and  one  million  six  hundred  thousand.  The  exudate  con- 
tained from  ten  to  fifteen  times  more  leucocytes  than  the  transudate.*    The 


*  In  the  sense  of  a  passive  effusion,  as  in  cardiac  dropsy. 


§58.]  INFLAMMATION.  247 

suppurative  character  of  a  fluid,  drawn  off  by  aspiration,  can  only  be  recog- 
nised macroscopically  when  it  contains  at  least  from  forty  to  sixty  thousand 
pus-cells  to  the  cubic  millimetre,  and  consequently  it  is  very  possible  for  a 
comparatively  large  amount  of  pus  to  be  present  in  a  fluid  without  its  being 
noticed. 

Composition  of  Pus. — Pus  consists  of  the  above-mentioned  cellular  ele- 
ments, which  are  called  pus-corpuscles,  and,  in  addition,  of  pus  serum.  If 
pus  is  allowed  to  stand  for  a  time  in  a  test  tube,  it  separates  into  two  layers 
the  upper  bright  yellow  layer  being  the  pus  serum,  and  the  lower  forming  a 
thick  deposit  made  up  principally  of  pu.s-corpuscles.  The  pus  serum  cor- 
responds to  the  plasma  of  the  blood  which  is  its  source,  but  often  differs 
from  it  chemically  very  materially.  There  are  ten  to  sixteen  per  cent,  of 
solid  elements  in  pus,  and  five  to  six  per  ceat.  of  ash.  The  gases  con.sist  of 
nitrogen  and  carbonic  acid  ;  ordinai'ily  there  is  no  oxygen  or  hydrogen. 
There  is  generally  a  somewhat  greater  amount  of  sodium  and  potassium  than 
in  blood  serum.  The  albuminous  substances  in  pus  consist  chiefly  of  para- 
globulin,  albuminate  of  potassium,  serum  albumen,  myosin,  leucin,  and 
tyrosin.  The  formed  constituents,  in  addition  to  the  pus-corpuscles,  include 
micro-organisms,  and  often  red  blood-cells,  fibrin,  fat  droplets,  fat  and 
cholesterin  crystals,  particles  of  necrotic  tissue,  etc.  Pus  which  contains 
fungi  usually  does  not  coagulate,  although  large  numbers  of  leucocytes  may 
be  present.  This  is  due  to  the  fact  that  there  is  no  fibrinogen  in  the  pus,  or 
rather  that  the  micro-organisms  change  the  fibrinogen  in  the  exuded  plasma 
into  peptone. 

Growth  of  Bacteria  in  Germ-free  Pus.— According  to  Eichel,  germ-free 
pus  contains  a  substance  which  is  deleterious  for  many  kinds  of  bacteria,  and 
small  quantities  of  the  staphylococcus  pyogenes  aureus  and  the  anthrax 
bacillus  will  perish  after  about  five  days,  but  the  streptococci  are  not  harmed. 
By  the  addition  of  putrefactive  bacteria  or  the  products  of  their  metabolism 
this  deleterious  pi-operty  is  increased.  The  reaction  of  pus  which  has  re- 
cently been  taken  from  the  body  is  alkaline,  but  it  becomes  acid  after  long 
exposure  to  the  air. 

Coloured  Pus. — Green  or  blue  pus  is  sometimes  found  instead  of  the  usual 
creamy,  more  or  less  yellow-coloured  variety.  This  discolouration  is  usually 
brought  about  by  the  presence  of  the  bacillus  pyocyaueus  (see  pages  313,  314), 
O.  Grube  and  Ferchmin  have  seen  fourteen  cases  of  bright  red  pus.  The 
cinnabar  colour  is  due  to  a  specific  bacillus  (see  page  314).  Orange-coloured 
pus  occurs  as  the  result  of  the  admixture  with  crystals  of  haematoidin. 

Outcome  of  an  Inflammation. — In  considering  tlie  outcome  of  an  in- 
flaiiiniation,  the  secondary  conditions  that  follow  must  be  distinguished 
from  the  purely  local  processes  at  the  seat  of  the  inflammation.  As 
regards  the  system  at  large,  the  main  purpose  of  inflammation  is  to  do 
away  with  tlie  causes  which  give  rise  to  the  inflammation,  accomplish- 
ing this  by  increased  metabolism,  rapidity  of  circulation,  and  transuda- 
tion. The  processes  which  take  place  in  an  inflammation  combat  its 
causes  in  an  efiicient  way,  and  try  to  make  reparation  for  the  damaging 
effects  that  it  produces  (Leber,  Arnold).     In  many  cases  the  inflamma- 


248  INFLAMMATION  AND  INJURIES. 

tion  is  not  capable  of  removing  the  causation  of  the  disease.  Death 
may  occur  at  any  stage  of  the  inflammation,  but  especially  when  the 
inflammatory  process  is  at  its  height,  as  a  result  of  a  general  systemic 
infection  with  fever,  due  to  the  primary  local  inflammation.  We  shall 
learn  in  §  62  about  the  significance  of  fever  and  its  dangers  for  the 
organism.  From  a  prognostic  standpoint,  the  location  of  the  inflam- 
mation is  of  the  greatest  importance.  A  subcutaneous  abscess  is  by 
no  means  as  dangerous  to  life  as  a  very  minute  collection  of  pus  in  the 
bones  of  the  skull,  the  meninges,  or  in  the  brain,  the  medulla  oblongata, 
etc.  The  age  and  constitution  of  the  patient  is  likewise  an  important 
factor. 

If  we  take  a  purely  local  view  of  the  outcome  of  an  inflammation, 
the  worst  that  can  occur  is  gangrene  or  necrosis — i.  e.,  death  of  the 
affected  tissues.  In  its  various  gradations  this  is  a  very  frequent  re- 
sult of  an  inflammation,  and  is  due  either  to  complete  stasis  in  the  ves- 
sels, followed  by  coagulation  of  the  blood  which  they  contain,  or  to 
'pressure  of  the  exudate  on  the  surrounding  tissue.  Furthermore,  in 
a  localised  death  of  tissue,  constitutional  conditions,  such  as  diabetes  or 
old  age,  play  a  very  important  part.  We  shall  return  to  the  discussion 
of  localised  death  of  tissue  (gangrene,  necrosis,  or  mortification)  in  an- 
other chapter.  It  will  only  be  stated  now,  that  in  general  the  extent 
of  the  inflammatory  necrosis  varies  greatly,  depending  upon  the  in- 
tensity and  extent  of  the  inflammation.  We  shall  see  that  the  influ- 
ence of  micro-organisms,  such  as  single  groups  of  bacteria,  is  a  promi- 
nent factor  in  the  production  of  gangrene.  The  capability  on  the  part 
of  the  tissues,  and  especially  of  the  vessels,  of  withstanding  gangrene 
varies  greatly  with  the  portion  of  the  body  which  is  affected  and  with 
the  individual.  The  most  favourable  outcome  of  an  inflammation  is  a 
complete  restitutio  ad  integrum — a  perfect  restoration  to  the  original 
condition— which  of  course  is  most  frequently  observed  after  an  inflam- 
mation of  a  mild  type  in  which  the  exudate  has  been  scanty  and  chiefly 
serous.  The  disappearance  of  the  phenomena  of  inflammation  begins 
as  soon  as  the  circulating  blood  has  restored  the  walls  of  the  blood- 
vessels to  their  normal  condition,  and  when  this  has  taken  place  the 
exudation  ceases.  The  fluid  portion  of  the  exudate  is  absorbed  by  the 
lymph  vessels,  likewise  the  white  blood-corpuscles  and  fibrin,  after  they 
have  in  part  undergone  a  fatty  degeneration.  The  red  blood-cells  lose 
their  colouring  matter,  and  gradually  become  disintegrated.  The  fixed 
tissue  cells  which  have  been  damaged  by  the  inflannnatory  irritation 
recover  after  the  restoration  of  their  normal  nutrition,  and  by  degrees 
a  complete  restitution  takes  place.  Sometimes,  however,  after  absorp- 
tion of  the  fluid  the  formed  or  solid  elements  of  the  exudate  remain 


§58.]  INFLAMMATION.  --  249 

behind  as  a  light  yellow,  caseous  mass,  which,  by  a  reactive  inflamma- 
tion, becomes  encapsulated  as  a  cheesy  nodule,  like  a  foreign  body. 
Under  such  conditions  complete  absorption  often  does  not  occur,  and 
finally  a  deposition  of  salts  of  lime  takes  place,  forming  a  firm,  calcare- 
ous concretion. 

If  the  inflammatory  process  is  more  severe,  and  if  there  is  localised 
death  of  tissue,  the  absorption  of  the  exudate  and  the  necrotic  soft 
parts  takes  place  in  a  similar  manner — i.  e.,  by  absorption  of  the  fluid 
and  fatty  emulsion  of  the  solid  elements.  Small  portions  and  granules 
of  tissue,  in  case  they  are  not  taken  up  by  the  lymph  channels,  are 
seized  by  the  cells  which  have  wandered  out  of  the  vessels,  and  which 
in  this  way  become  granular  cells.  If,  as  the  result  of  an  inflammation, 
a  portion  of  bone  has  become  necrotic,  the  dead  piece  of  bone  or 
sequestrum  is  separated  from  the  living  bone  by  a  suppurating  line  of 
demarcation  (see  §  106).  The  pus  formed  during  an  inflammatory  pro- 
cess near  the  surface  of  the  body  may  break  through  spontaneously,  or 
be  removed  artificially  by  operative  measures,  such  as  incision,  etc. 

There  is  the  danger  in  all  infectious  inflammations,  or  those  cases 
of  suppuration  which  are  due  to  micro-organisms,  that  the  inflamma- 
tion may  become  the  starting-point  for  a  general  infection.  There- 
fore, whenever  it  is  possible,  operative  measures  should  be  undertaken 
at  an  early  period  to  provide  a  way  of  escape  for  the  exudate,  for 
otherwise  the  inflammation  and  suppuration  may  spread,  resulting  in 
an  extensive  infiltration  or  phlegmon,  which  may  break  through  into 
an  important  organ,  such  as  a  joint,  the  cranial  cavity,  abdominal  cav- 
ity, etc.  Moreover,  the  micro-organisms  that  cause  the  inflammation 
are  scattered  about  by  the  lymph-  and  blood-vessels.  It  must  always 
be  borne  in  mind  that  products  are  constantly  being  formed  in  an 
infectious  inflammation  which  are  capable  of  producing  further  inflam- 
mation in  the  surrounding  parts  and  in  widely  separated  organs.  The 
bacteria,  and  the  products  of  metabolism  and  decomposition  which 
they  cause,  are  here  again  the  causes  of  the  secondary  inflammatory 
processes.  As  a  result,  then,  of  infectious  inflammations,  bacteria  may 
be  deposited  in  large  numbers  in  different  internal  organs,  causing  sec- 
ondary so-called  metastatic  abscesses. 

Scar  Formation. — If  a  defect  or  loss  of  substance  results  from  a 
severe  inflammation  with  necrosis,  this  is  remedied  to  a  greater  or  less 
extent  by  a  new  production  of  connective  tissue,  which  is  then  called 
cicatricial  tissue.  Scar  formation  is  to  be  looked  upon  as  an  inflam- 
matory process  which  is  productive  in  character.  A  germinal  or  granu- 
lation tissue,  as  it  is  called,  develops,  consisting  only  of  round  cells 
with  a  very  small  amount  of  interstitial  substance;  this  granulation  tis- 


250  IXFLAMMATIOX   AND   INJURIES. 

sne  then  gradually  changes  into  fibrous  connective  tissue,  Tvhich  makes 
up  the  cicatrix,  I  used  to  believe,  as  Cohnheim  did,  that  the  new- 
formed  connective  tissue,  the  granulation  and  cicatricial  tissue,  was 
chiefly  derived  from  the  emigrated  leucocytes,  which  increased  in  size 
when  the  new  blood-vessels  developed  amongst  them  and  became  large, 
irregular-shaped  cells  (fibroblasts).  But  some  recent  investigations 
have  made  me  conclude  that  the  leucocytes  at  the  inflammatory  focus 
are  unflt  for  making  new  connective  tissue  and  healing  up  the  wound, 
and  I  am  now  convinced  that  they  gradually  disappear,  partly  by  wan- 
dering into  the  lymphatic  vessels  and  being  carried  off  in  the  lymph 
current,  and  partly  by  wandering  into  other  localities  and  disintegrat- 
ing and  being  taken  up  by  the  fixed  cells  of  the  part  (Baumgarten, 
Zahn,  Marchand,  etc.).  Ziegler  has  also  expressed  the  same  view.  The 
newly  formed  connective  tissue,  therefore,  is  in  reality  produced  by  a 
growth  of  the  fixed  connective-tissue  cells  (Baumgarten,  ^larchand, 
etc.).  Marchand  has  proposed  to  designate  the  leucocytes  originating 
from  the  blood  and  lymphatics  as  exudation  cells,  in  contradistinction 
to  the  granulation  or  true  formative  cells  which  are  derived  from  the 
tissues.  The  formative  cells  get  their  nourishment  from  the  protoplasm 
of  the  leucocytes,  as  I  have  mentioned  above.  Sherrington,  Ballance, 
Shattock  and  others  maintain  that  tlie  plasma  cells  are  the  ones  chiefly 
concerned  in  the  formation  of  cicatricial  tissue  (see  also  §  61). 

Eegeneration  of  the  Tissass. — Simultaneously  with  the  formation  of 
the  granulation  or  cicatricial  tissue  there  is  a  proliferation  of  the  fixed 
(specific)  cells  in  the  neighbourhood  for  the  purpose  of  restoring  the 
cells  that  make  up  the  particular  organ.  Epithelium  gives  rise  to 
epithelium ;  muscle  cells  form  muscular  fibres,  though  in  a  very  limited 
amount ;  periosteal  and  medullary  cells  make  bone,  etc.  The  power  of 
regeneration  possessed  by  the  different  tissues  varies  very  greatly,  as 
we  shall  see.  The  skinning  over  or  covering  of  a  loss  of  substance  in 
the  skin  vrith  epidermis  is  brought  about  by  the  cells  of  the  rete  Mal- 
pighii  and  sebaceous  glands.  Reference  is  made  to  §  61  for  the  de- 
scription of  the  various  phenomena  in  scar  formation  and  regeneration 
in  the  different  tissues  (microscopic  phenomena  in  the  healing  of  a 
wound),  and  to  §§  S7  and  88,  (Injuries  of  Soft  Parts;.  For  the  process 
of  healing  of  fractures  see  §  101. 

The  healing  of  a  Foreign  Body  into  a  Wound.— If  the  inflammation  is 
caused  by  the  entrance  into  the  tissues  of  a  solid  foreig'u  body,  the  latter  may 
completely  heal  into  the  tissues,  as  we  shall  often  have  the  opportunity  of 
observing^ ;  and  this  will  occur  the  more  readily  the  more  free  the  body  is 
from  dirt,  dust,  bacteria,  products  of  decomposition,  etc.  We  know  that  silk 
sutures,  silver  wire,  bullets,  etc.,  heal  up  in  a  wound  in  this  way  without  giv- 


§58.]  INFLAMMATION.  251 

ing  rise  to  any  reaction.  Foreign  bodies  which  have  thus  become  enclosed 
often  change  tlieir  location  later  on,  and  in  their  wanderings  may  make 
their  appearance  beneath  the  skin  in  another  portion  of  the  body.  Large, 
soft  foreign  bodies  are  completely  absorbed  in  the  way  described  above.  I 
implanted,  under  antiseptic  precautions,  large  fresh  pieces  of  liver,  spleen, 
lung,  and  even  entire  kidneys  of  rabbits,  in  the  peritoneal  cavities  of  other 
rabbits,  and  found  that  they  became  absorbed  without  producing  peritonitis. 
I  also  used  similar  specimens  which  had  been  hardened  in  absolute  alcohol, 
and  with  the  same  results.  The  portions  of  tissue  were  invaded  by  vast  num- 
bers of  wandering  cells  and  slowly  liquefied. 

Hallwachs,  Rosen berger,  Salzer  and  others  have  recently  studied  the  sub- 
ject of  the  encapsulation  of  foreign  bodies,  and  Salzer  says  that  those  which 
are  smooth  and  solid  become  enclosed  in  a  delicate  connective-tissue  capsule, 
while  the  porous,  fibrous,  rough  foreign  bodies  are  most  apt  to  heal  into  the 
scar  tissue  with  the  formation  of  very  thick  layers  of  connective  tissue. 

Diagnosis  of  Inflammation. — In  the  diagnosis  of  inflammation — i.  e., 
of  the  four  above-described  cardinal  symptoms,  redness,  swelling, 
heat,  and  pain — we  niake  special  use  of  inspection  and  palpation  of  the 
affected  part  in  case  it  can  be  seen  and  touched.  If  the  inflammation 
is  located  on  the  outer  surface  of  the  body  the  diagnosis  is  simple,  but 
it  is  more  difficult  if  the  inflammation  is  situated  more  deeply.  By 
palpation  of  the  inflamed  tissues  we  attempt  to  determine  whether  the 
inflammatory  focus  contains  pus — i.  e.,  whether  it  "  fluctuates  "  or  not. 
Every  fluid,  and  consequently  pus  or  serum,  contained  in  a  cavity  hav- 
ing yielding,  elastic  walls  will  give  fluctuation  or  a  wave  movement 
when  the  fluid  in  this  cavity  is  set  in  motion  by  intermittent  pressure 
with  the  index  or  middle  finger.  The  detection  of  fluctuation  is  of 
the  greatest  practical  importance.  If  the  pus  is  contained  within  firm, 
unyielding  walls,  such  as  bone,  or  in  deeply  situated  tissue  with  thick- 
ened rigid  walls,  fluctuation  cannot  be  made  out.  Furthermore,  it 
must  not  be  confused  with  the  pseudo-fluctuation  manifested  upon  pal- 
pation of  soft  elastic  parts  ;  but  a  little  experience  will  soon  teach  the 
distinction  between  the  fluctuation  of  an  elastic  cavity  filled  with  fltiid 
and  the  pseudo-fluctuation  of  soft  elastic  tissues  such  as  the  muscles  of 
the  thenar  eminence,  soft  fatty  tumours,  etc.  Puncture  with  a  bypo- 
dermic  syringe  is  an  exceedingly  useful  diagnostic  measure  for  de- 
termining the  nature  of  the  contents  of  an  inflammatory  focus  (see 
page  ri). 

"We  also  employ  the  sense  of  hearing  in  the  diagnosis  of  an  inflam- 
mation by  noting,  for  example,  whether  any  friction  sound  is  produced 
by  the  rubbing  together  of  two  opposed  inflamed  surfaces.  Hueter 
has  constructed  instruments  analogous  to  the  stethoscope  used  in  the 
diagnosis  of  diseases  of  the  thoracic  viscera ;  they  are  a  dermatoj)hon, 


252  INFLAMMATION  AND   INJURIES. 

an  osteophon,  and  a  myophon,  for  the  diagnosis  of  surgical  diseases  of 
the  skin,  bones,  and  muscles  respectively,  and  they  consist  of  an  elastic 
tube  fitted  to  an  ear-piece.  "VYe  shall  refer  to  this  apparatus  in  diseases 
of  bone,  but  it  may  be  said  here  that  hitherto  it  has  not  been  brought 
into  general  use. 

The  febrile  disturbance  accompanying  an  inflammation  is  deter- 
mined by  accurate  measurement  of  the  body  heat  by  means  of  a  ther- 
mometer placed  in  the  axilla,  or,  better,  in  the  rectum  (see  §  62,  Fever). 

Amongst  other  aids  to  diagnosis  I  should  mention  the  probe,  which 
is  used  to  ascertain  the  direction  and  length  of  a  fistulous  tract,  or  the 
presence  of  a  foreign  body.  There  are  also  instruments  designed  for 
special  organs,  such  as  the  urethra,  bladder,  stomach,  etc.,  and  a  great 
number  of  contrivances  for  inspection  of  the  nose,  larynx,  bladder, 
eye,  etc. 

These  general  remarks  will  be  sufficient  until  we  return  to  the  diag- 
nosis of  inflammations  of  the  separate  parts  of  the  body. 

Treatment  of  Inflammation. — At  present  we  can  only  deal  briefly 
with  the  treatment  of  inflammation,  as  we  shall  have  to  come  back  to 
the  subject  in  detail  for  each  separate  part  of  the  body.  From  a  pro- 
phylactic standpoint  it  is  best  to  treat  every  injury,  no  matter  how 
trifling  it  may  be,  on  antiseptic  principles,  after  the  manner  described 
in  a  former  chapter.  In  general,  the  treatment  of  an  acute  inflamma- 
tion consists  in  the  use  of  suitable  antiphlogistic  measures,  particularly 
'  the  proper  position  of  the  inflamed  part,  such  as  elevation  in  the  case 
of  an  extremity,  in  the  application  of  ice,  and  in  the  ])rompt  evacuation 
of  the  pus  or  inflltrating  exudate  by  incision. 

Blood-letting  by  leeches,  cupping,  and  scarification  u'sed  to  be  much 
in  vogue  for  diminishing  the  amount  of  blood  contained  in  an  in- 
flamed portion  of  the  body,  but  now  this  practice  lias  very  properly 
been  given  up.  The  counter-irritation  method  of  treatment  by  cutane- 
ous irritants,  such  as  the  moxa,  issue,  red-hot  iron,  painting  with  tinc- 
ture of  iodine,  and  the  application  of  vesicants,  is  also  old-fashioned. 
It  would  require  too  much  space  to  give  the  outlines  of  treatment  for 
inflammation  according  to  the  location  and  causes  of  the  latter,  and  it 
can  be  done  more  satisfactorily  in  the  discussion  of  the  treatment  of 
inflammations  of  the  separate  organs.  The  treatment  of  the  general 
febrile  disturbance  due  to  inflammation  will  be  considered  in  the  treat- 
ment of  fever  (§  62). 

§  59.  Morphology  and  General  Significance  of  Micro-organisms. — By 
micro-organisms  or  mieroles  is  understood  a  class  of  minute  living 
organisms  which  belong  to  the  lowest  forms  of  plant  life  or  stand  on 
the  border  line  between  plants  and  animals.     The  majority  of  the  mi- 


§59.]  MICRO-ORGANISMS.  253 

cro-organisms  liave  a  diameter  of  only  about  one  micromillimetre  or 
less.  They  niultii)ly  with  extreme  rapidity,  and  are  able  to  live  in 
widely  dilfering  degrees  of  temj^eratnre,  some  in  aeid  and  others  in 
alkaline  solutions  of  simple  compounds  (with  the  exception  of  carbon 
dioxide),  as  well  as  of  more  complex  nourishing  substances. 

The  micro-organisms  play  a  very  important  part  in  the  economy  of 
nature.  They  excite  fermentation  and  decomposition,  and  are  parasites 
in  living  plants,  animals,  and  man,  causing  in  some  cases  disease  and 
death.  By  fermentation  and  decomposition  the  micro-organisms  dis- 
integrate considerable  amounts  of  organic  material  in  a  short  period  of 
time  with  the  evolution  of  gas.  The  change  of  sugar  into  lactic  acid 
(sour  milk),  the  lactic  into  butyric 'acid,  and  alcohol  into  acetic  acid, 
are  all  processes  of  fermentation  caused  by  micro-organisms.  AYe  make 
use  of  micro-organisms  in  the  preparation  of  many  alimentary  sub- 
stances, such  as  bread,  cheese,  beer,  wine,  etc.,  while  on  the  other  hand, 
as  a  result  of  the  fermentative  and  putrefactive  action  of  these  low 
orders  of  organisms,  our  food  may  be  rendered  unfit  to  eat. 

Micro-organisms  also  produce  poisonous  matters  (ptomaines,  tox- 
ines)  which  are  dangerous  to  the  health  and  life  of  man.  Kumerous 
acute  and  chronic  inflammations,  particularly  the  surgical  diseases  of 
wounds,  are  due  to  the  presence  of  micro-organisms. 

Evidence  of  the  Bacterial  Origin  of  many  Infectious  Diseases,  especially 

the  Diseases  of  Wounds. — Under  normal  couditions  we  find  no  micro-organ- 
isms in  the  blood  and  internal  organs  of  healthy  human  beings  and  animals; 
this  has  been  proved  beyond  a  doubt  by  Meissner  and  many  other  investi- 
gators. On  the  other  hand,  we  observe  in  the  various  infectious  diseases, 
particularly  the  surgical-wound  diseases,  certain  micro-organisms  in  the 
blood  and  internal  organs,  and  we  know  that  every  infectious  disease  is  due 
to  some  specific,  plainly  distinguished  class  of  micro-organism.  These  gain 
access  to  the  body  from  without  by  means  of  the  inspired  air,  the  food,  water, 
or  by  contact  with  the  surface  of  the  body,  especially  if  thei'e  is  an  interrup- 
tion of  continuity  in  the  skin  or  mucous  membranes.  The  striking  results 
obtained  by  antisepsis  and  the  aseptic  method  of  operating  and  treating 
wounds  demonstrate  that  the  infectious- wound  diseases  are  caused  by  the 
entrance  of  micro-organisms'  into  the  wound  from  without.  If  we  perform 
an  operation,  taking  every  precaution  not  to  introduce  microbes  by  our 
hands  or  instruments,  or  from  the  patient's  own  skin,  into  the  wound,  or, 
briefly,  if  we  operate  aseptically,  as  we  have  learned  in  a  previous  chapter, 
with  eveiything  germ-free  and  sterile,  and  then  dress  the  wound  with  germ- 
free  fsterilised)  materials,  such  a  wound  will  invariably  heal  without  inflam- 
mation and  suppuration  per  primam  mtentionem,  or,  in  other  words,  by 
immediate  agglutination  of  its  borders,  and  without  giving  rise  to  fever.  If 
there  is  a  transgression  of  the  rules  of  asepsis  or  antisepsis  in  performing  an 
operation  or  treating  a  wound,  and  if  micro-organisms  get  into  the  wound, 
inflammation  and  suppuration  and  other  wound  diseases,  accompanied  by  a 


254 


INFLAMMATION   AND   INJURIES. 


corresponding'  febrile  disturbance,  will  result.  If  an  infected  wound  is  treated 
with  disinfecting-  substances,  such  as  bichloride  (1  to  1,000  -  5,000)  or  three- 
per-cent.  carbolic  solutions,  the  micro-organisms  are  prevented  from  further 
development  and  the  existing  inflanmiation  or  suppuration  is  modified  or 
checked,  provided  it  has  not  already  become  too  far  advanced  and  no  general 
systemic  poisoning  has  taken  place.  A  further  proof  of  the  microbic  origin 
of  the  infectious  diseases  is  furnished  by  the  successful  results  of  transmis- 
sion from  animal  to  animal.  Cultui-es  of  a  particular  kind  of  bacteria  which 
had  caused  a  certain  infectious  disease,  were  inti'oduced  into  the  body  of  an 
animal  and  here  produced  the  same  disease,  and  the  same  kind  of  bacteria 
could  be  isolated  from  the  diseased  tissues.  The  micro-organisms  damage  the 
human  organism  in  a  double  manner— viz., 'by  the  formation  of  the  poison- 
ous products  of  their  metabolism,  and  by  multiplying  very  rapidly  and  invad- 
ing new  portions  of  tissue. 

The  Different  Kinds  of  Micro-organisms. — We  recognise  four  large 
classes  of  micro-organisms :  I.  The  fungi  or  moulds.  II.  The  sprout- 
ing or  yeast  fungi  (saccharomycetes,  blastomycetes).  III.  The  fission 
fungi,  bacteria  (schizomyc6tes).     IV.  Mycetozoa  and  protozoa. 

I.  Fungi. — Moulds  form  the  well-known  green,  yellow,  whitish,  or  black 
skin-like  covering  found  upon  all  sorts  of  dead  organic  substances.     They 

usually  consist  of  two  functionally  distinct  parts, 
the  mycelium  and  the  germinal  hypha  or  zy- 
gospore. The  mycelium  consists  of  branching, 
usually  jointed  threads,  which  anastomose  with 
one  another  and  proliferate  in  the  nutrient 
substrata.  The  zygospores  spring  from  the  my- 
celium and  produce  and  carry  on  their  ends  the 
seeds  or  spores  (Fig.  221).  The  latter  are  round 
or  elongated  cells  generally  having  a  dense  en- 
veloping membrane,  and  after  separation  from 
the  zygospore  are  capable  of  forming  another 
fungus  with  its  zygospore.  The  spores  can  re- 
tain their  vitality  in  a  dry  state  for  from  two 
to  ten  years.  Numerous  species  of  fungi  are 
distinguished  by  the  manner  in  which  the  spores 
form  vipon  the  zygospores.  Occasionally  the 
spores  undergo  segmentation  by  transverse  di- 
vision of  the  terminal  cells  at  the  extremity  of 
the  zygospore  (conidia).  In  other  fungi  the 
terminal  cell  develops  into  the  so-called  sporan- 
gium or  ascus,  in  the  interior  of  which  the  spores  form  by  division  of  the 
plasma  (ascospoi'es) .  In  still  others  two  zygospores  grow  one  within  the 
other,  and  the  so-called  oospores  develop  at  the  point  of  junction  of  the  two 
spore  carriers.  The  same  fungus  will  occasionally  form  its  spores  in  several 
different  ways,  depending  upon  the  conditions  in  which  it  exists  (conidia  and 
ascospores). 

Conditions  suitable  for  the  Life  of  the  Fungi. — The  fungi  are  found  upon 


Fig.  221. — PeniciHium  glaucuni, 
X  500. 


§59.]  MICRO-ORGANISMS.  255 

every  description  of  dead  substance,  and  upon  substances  which  contain  a 
relatively  small  amount  of  water  and  have  an  acid  reaction,  thus  differing 
from  tlie  bacteria.  For  making  pure  cultures  of  fungi,  the  best  materials  are 
boiled  potatoes,  bread  pulp,  and  gelatine,  or  the  agar  mixture  rendered  acid 
by  tlie  addition  of  two  to  five  per  cent,  of  tartaric  acid,  to  prevent  bacteria 
from  taking  root  along  with  tlie  fungi.  The  temperature  is  an  important 
matter,  some  species  thriving  best  at  +15°  C.  (59°  F.),  and  another  at  +40°  C 
(104°  F.).  The  spores  will  only  form  when  there  is  plenty  of  air,  oxygen 
being  essential,  and  consequently  most  of  the  fungi  will  not  multiply  in  the 
interior  of  animal  tissues  nor  in  blood  ;  they  ordinarily  exist  only  upon  such 
portions  of  the  body  as  are  freely  exposed  to  the  atmospheric  air. 

Penicilliuiu. — The  commonest  fungus  is  the  penicillium  glaucum  (Fig. 
221).  It  grows  in  distilled  water  and  many  kinds  of  medicine,  best  at  a  tem- 
perature of  from  15°  to  20°  C.  (59°  to  68°  F.),  while  at  38°  C.  (101°  F.)  it 
gradually  dies.  The  mycelium  has  a  flocculent,  white  appearance,  turning 
green  after  the  formation  of  the  spores.  The  latter  do  not  grow  when  intro- 
duced into  warm-blooded  animals  by  injection  into  the  blood  or  by  inhala- 
tion, and  they  may  remain  for  weeks  in  the  liver  and  spleen. 

Oidium. — There  are  numerous  species  of  the  oidium  which  flourish  partly 
upon  a  dead  substratum  and  partly  (like  mildew)  upon  living  plants.  They 
are  regularly  present  upon  sour  milk.  Mycelium  and  spores  are  white. 
They  thrive  best  at  a  temperature  between  19°  to  30°  C.  (50°  to  86°  F.).  They 
have  plain,  upright  zygospores,  bearing  chains  of  cylindrical  spores.  Fungi  of 
the  oidium  class  are  found  in  favus,  pityriasis  versicolor,  and  herpes  tonsurans. 

Monilia.— The  monilia  is  distinguished  from  the  oidium  by  its  zygospore, 
which  takes  a  bushy-shaped,  branching  form  as  it  springs  from  the  myce- 
lium.    It  causes  thrush. 

Mucor. — There  are  many  species  of  mucor,  some  of  which  thrive  best  at  a 
temperature  of  37°  C.  (98'6°  F.),  and  cause  death  in  rabbits  when  their  spores 
are  injected  into  the  blood-vessels  in  large  amounts.  There  are  then  found 
in  the  internal  organs,  particularly  the  kidney,  a  great  number  of  small 
fungi  which  do  not  fructify.  They  are  chiefly  found  in  man,  in  the  external 
auditory  meatus.     The  spores  are  developed  in  sporangia. 

Aspergillus. — They  generally  germinate  like  the  conidia,  less  frequently 
having  ascospores.  The  aspergillus  glaucus  is  greenish  yellow,  is  harmless 
as  regards  warm-blooded  animals,  and  is  generally  found  in  damp  walls, 
fruits  wdiich  have  been  stored  away,  etc.  The  aspergillus  niger,  fumigatus, 
flavescens,  and  subfviscus  are  pathogenic,  and  the  maximum  temperature 
compatible  with  their  existence  is  about  37°  C.  (98"6°  F.).  The  injection  of 
large  numbers  of  the  spores  will  kill  rabbits,  numerous  foci  of  the  fungus 
being  found  in  the  heart,  liver,  and  kidneys.  Spores  of  aspergillus  fumi- 
gatus exist  chiefly  in  the  air-passages  of  birds.  In  man,  colonies  of  this 
species  of  aspergillus  have  been  observed  in  the  bronchi,  lungs,  external 
auditory  meatus,  upon  the  cornea,  etc. 

Actinomyces. — The  actinomyces  or  ray  fungus  is  found  in  cattle  and  man 
chiefly  in  the  tongue,  jaw,  and  lungs,  where  it  causes  abscess  and  suppurat- 
ing grow^ths.  Harz,  De  Barry  and  others  placed  the  actinomyces  amongst 
the  fungi,  but  the  recent  investigations  of  Israel,  Ponfick  and  Bostroem  seem 
to  prove  it  to  be  a  branched  form  of  cladothrix  (see  §  86,  Actinomycosis). 


256  INFLAMMATION  AND   INJURIES. 

Pathological  Importance  of  the  Fungi  in  Man.— The  pathological  bearing 
of  the  fungi  upon  man,  as  ascertained  by  experimental  and  clinical  observa- 
tions, is  briefly  as  follows:  It  is  well  known  that  the  fungi  occasionally  find 
lodgement  in  the  epithelium  of  the  skin  and  mucous  membranes,  and  in  the 
former  situation  give  rise  to  favus,  herpes  tonsurans,  and  pityriasis  versi- 
color, and  in  the  latter  to  thrush.  E.  Wagner  has  noticed  that  the  threads  of 
the  thrush  fungus  penetrate  into  the  blood-vessels  of  the  mucous  membrane; 
and  Zenker  found  in  the  brain  of  a  child  afi'ected  with  thrush  multiple 
abscesses  with  sprouting  spores  of  the  thrush  fungus  in  their  centres.  Fungi 
are  capable  of  growing  in  the  tissues  of  warm-blooded  animals  through 
which  blood  is  circulating.  Grohe  at  first  denied  this,  but  it  was  subse- 
quently affirmed  by  Grawitz,  though  the  fungus  has  to  undergo  an  "  accom- 
modative cultivation  "  before  it  can  live  in  the  alkaline  blood  at  a  temperature 
of  39°  C.  (102'2°  F.).  Experiments  made  by  Koch  and  others  have  demon- 
strated that  there  are  pathogenic  fungi  which  are  capable  of  development 
in  the  tissues  of  warm-blooded  animals  without  having  undergone  any  pre- 
vious particular  kind  of  cultivation,  while  the  non-pathogenic  fungi  never 
possess  this  power  even  though  they  have  first  been  subjected  to  cultivation. 
The  non-pathogenic  fungi  include  the  penicillium  glaucum,  the  aspergillus 
glaucus  and  niger,  the  mucor  raucedo,  and  stolonifer.  The  species  which 
are  certainly  pathogenic  include:  1.  The  aspergillus  fumigatus,  distinguished 
from  the  aspergillus  glaucus  by  its  very  small  size  and  that  of  its  spores,  its 
dirty  green  colour,  the  manner  of  its  growth,  its  poor  development  at  ordi- 
nary temperatures,  and  the  very  rapid  growth  manifested  in  temperatures 
equal  to  blood  heat.  The  aspergillus  fumigatus  is  present  in  bread,  and  is 
readily  cultivated  on  dough  kept  at  a  temperature  of  39°  to  40°  C.  (102-2°  to 
104°  F.),  as  a  dark-green  fungous  covering.  2.  The  aspergillus  flavescens 
is  similar  to  the  aspergillus  fumigatus,  and  is  characterised  by  its  yellowish- 
green  colour.  3.  The  mucor  rhizopodo-formis  is  distinguished  from  the  non- 
pathogenic rancor  (Rhizopus)  by  the  greyish-brown  colour  of  its  mycelium, 
the  large  size  of  its  individual  parts,  its  small,  round,  colourless  spores,  and 
by  the  egg-shaped  columella  dilated  at  its  top.  4.  The  mucor  corymbifer  is 
known  by  the  snow-white  colour  of  its  mycelium  and  its  characteristic  form. 

Internal  fungous  diseases  arising  spontaneously  in,  for  instance,  the  lungs 
and  intestinal  tract,  are  seldom  seen  in  man,  as  the  pathogenic  fungi  (of  the 
aspergillus  and  mucor  varieties)  will  only  thrive  at  a  high  temperature,  and 
consequently  are  not  very  plentiful  in  the  air,  water,  or  alimentary  sub- 
stances. Furthermore,  the  fungi  are  only  pathogenic  when  they  exist  in 
great  numbers,  while  the  system  is  capable  of  overcoming  a  few  of  them 
without  itself  suffering  harm  (Grawitz),  and  their  increase  by  means  of  spores 
does  not  take  place  in  living  tissue.  Fungous  diseases  are  most  easily  excited 
by  intravenous  injection  of  the  organisms.  Lichtheim's  mucor  injections 
proved  fatal  in  rabbits  in  every  case,  while  dogs  were  not  affected  at  all. 
Morse,  Kaufmann  and  Schulz  caused  animals  to  inhale  and  swallow  large 
amounts  of  pathogenic  fungi  without  producing  any  ill  effect  ;  Lichtheim 
noted  only  a  scanty  and  stunted  vegetation  in  the  lungs  after  inhalation.  In 
man  there  is  occasionally  observed  a  pneumomycosis  aspergillina  (aspergillus 
fumigatus)  and  a  pneumomycosis  mucorina,  secondary  to  already  existing 
pulmonary  disease.     There  is  also  a  ^keratomycosis  aspergillina,  a  corneal 


§59.]  MICRO-ORGANISMS.  257 

lesion,  and  an  asperjrillus  mycosis  of  the  external  auditory  meatus  (oto-  or 
myringo-myeosis  aspergillinu),  produced  by  the  aspergilhis  fuuiigatus,  fla- 
vescens,  and  nigrescens.  According  to  Carter,  the  Madura  foot,  a  disease  like 
elephantiasis,  endemic  in  India,  and  characterised  by  the  formation  of  warty 
lumps,  suppurating  in  their  interior  and  terminating  in  death  after  about  a 
year,  is  caused  by  a  fungus,  the  chionyphe  Carteri,  related  to  the  mucor  sto- 
lonifer;  but  other  investigators  have  disputed  this.  As  a  general  thing,  man 
may  be  said  to  be  immune  to  the  pathogenic  fungi  hitherto  identified  ;  but 
under  conditions  not  yet  understood  these  fungi  may  take  on  a  fatal  activity, 
as  exemplified  by  the  above-mentioned  case  of  Zenker's,  and  a  recently  de- 
scribed and  interesting  case  of  Paltauf,  in  which  a  man  died  in  coma  after 
what  appeared  to  be  an  enteritis  and  peritonitis.  In  the  brain,  lungs,  and 
intestine  were  found  inflammatory  foci,  or  abscesses,  containing  mycelia  of 
the  mucor  variety  (mucor  corymbifer).  It  is  by  no  means  impossible  that 
still  other  new  forms  of  fungous  disease  may  be  found  to  have  their  existence 
in  man.  All  the  facts  which  are  known  as  regards  the  pathogenic  fungi  are 
of  great  surgical  interest.  The  fungi  play  a  very  important  part  in  the  pro- 
duction of  diseases  in  plants  and  low  orders  of  animal  life,  such  as  the  grape 
disease,  the  potato  disease,  the  "rof  of  grain,  the  muscardine  disease  of  silk- 
worms, and  various  diseases  in  insects,  etc. 

II.   The  Yeast  Fungi  (Blastomycetes).— The  yeast  fungi  (Fig.  222 1  are 
round,  oval  cells  of  different  sizes,  varying  from  two  to  fifteen  micromillime- 
tres  in  diameter,  having  a  tnm  enveloping  membrane  and 
granular  protoplasm,  in  which  there  are  frequently  vacu- 
oles (Fig.  222).     They  multiply  by  budding  or  putting  forth 
daughter  cells,  which  finally  become  separated  from  the 
mother  cells  by  a  partition,  and  either  remain  in  contact 
with  their  parent  cell  for  a  considerable  time,  forming  more 
or   less   long  chains,  or  they  become   entirely  sejiarated. 
Many,  though  not  all.  of  the  yeast  fungi  produce  in  solu-     ^'p-    222.  —  Yeast 
tions  of  sugar  alcoholic  fermentation,  changing  grape  sug-        romyces  cerrevi- 

ar  into  carbonic  acid  and  alcohol.     Tlie  true  veast-fungi        =''*•  ^  acuoles  are 

.  'it  present   in    some 

which  cause  fermentation  fsaccharomycetes)  must   be  dis-        ofthe  larger  cells. 

tinguished  from  the  other  fungi  of  the  same  class.  The 
mycelia  of  the  t%-pical  mould  fungus — for  instance,  the  mucor  species — can 
form  chains  and  can  cause  alcoholic  fermentation  in  a  solution  of  sugar. 
Macroscopically  the  yeast  plant  forms  a  white  cloudy  sediment  in  a  ferment- 
ing fluid,  or  a  white  scum  over  the  surface  of  alcoholic  fluids  which  are  spoil- 
ing. In  solid  nutritive  media  (gelatine)  the  yeast  fungus  makes  spores  by 
developing  free  cells  within  the  enlarged  mother  cell  (ascosporesj.  Beer-wort 
and  decoctions  of  malt  or  prunes,  to  which  sugar  is  afterwards  added,  form 
the  best  culture  media,  but  they  must  be  mixed  with  one  per  cent,  of  tartaric 
acid  to  keep  out  the  bacteria. 

The  pathological  interest  of  the  yeast  fungi  is  limited  ;  they  occasionally 
give  rise  to  fermentation  in  the  stomach.  Some  writers  think  that  thrush  is 
caused  by  a  variety  of  the  yeast  ftmgus  (m\-coderma). 

III.  The  Bacteria  iSchizomycetes). — The  bacteria  (from  to  ^aicn]pLov, 
a  small  rod,  from  the  rod  shape  which  many  of  them  have)  are  very 
18 


258 


INFLAMMATION  AND  INJURIES. 


h 


..Sft 


•''*Mi 


'•^v-:;^^^ 
^v^' 


•.'.« 


.V 


Fig.  2-23. — Different  varieties  of  cocci:  a,  Small- 
er and  larger  cocci ;  6,  diplococci ;  c,  chain 
coccus  (streptococcus) ;  d  e,  clusters  of  cocci 
in  the  form  of  a  bunch  of  grapes  (staphylo- 
cocci) ;  /,  sarcina  (packet  coccus) ;  ff,  micro- 
coccus tetrajjonus. 


small,  simple  cells  of  a  low  order  of  vegetable  life  related  to  the 
lower  orders  of  algae.  Tliey  are  divided  into  several  distinct  classes, 
according  to  their  shape  and  the  effects  which  they  produce.  Never- 
theless, under  altered  conditions  in  their  life  the  bacteria  of  one  class 
change  their  shape  and  function  to  a  greater  or  less  degree.     There 

are  chieHy  to  be  distinguished — 
1.  The  micrococci.  2.  The  ba- 
cilli.    3.  The  spirilli. 

1.  The  Spherical  Bacterium 
{Micrococcus  or  Coccus). — The 
micrococci  are  small,  round  or 
oval  cells,  which  by  division  or 
iission  always  produce  in  turn  the 
same  round  cells.  The  micro- 
cocci exist  either  as  isolated  sphe- 
rules (Fig.  223,  a),  or  they  remain 
in  pairs  after  dividing  (diplococ- 
cus,  Fig.  223,  h),  or  the  spherules 
cling  together  in  chains  (strep- 
tococcus, Fig.  223,  c).  In  other  instances  they  form  irregular  groups 
(staphylococcus.  Fig.  223,  d,  e).  Large  groups  or  colonies  bound  to- 
gether by  some  sticky  material  such  as  mucus  are  called  zoogloa. 
Sometimes  the  micrococci  develop  in  groups  of  four  (merismopaedia, 

merista.   Fig.   223,  g),  or 

V-    -5-  they  are  ioined   together 

in  cubes  (sarcina,  Fig. 
223,  f).  The  sarcina  is 
found  in  the  stomach  of 
man,  as  sarcina  ventriculi, 
wlien  decomposition  of 
the  gastric  juice  is  present. 
2.  Rod-shajx'd  Bacte- 
ria {the  Bacillus). — In  all 
bacilli  the  longitudinal  di- 
ameter exceeds  the  trans- 
verse, and  their  size  varies 
very  greatly  (Figs.  224, 
225,  22*]).  ^  The  bacilli 
divide  .transversely,  and, 
like  the  cocci  or  the  strep- 
tococci^ they  form  longer  or  shorter  threads  by  remaining  attached  to 
one  another  after  division  (leptothrix.  Fig.  226).     These  threads,  in 


Fig.  224.— Tubercle  bacilli  (lung),  x  TOO  (Koch). 


§59.] 


MICRO-ORGANISMS. 


259 


contrast  to  the  mould  fungi,  never  become  branched,  though  several 
threads  lying  next  each  other  may  give  the  appearance  of  branches. 
Particularly  the  anthrax  bacilli  (Fig. 
226)  and  the  bacilli  of  malignant  oede- 
ma have  the  form  of  long  threads. 
Many  bacilli  possess  an  enlargement  at 
their  centre  or  end,  ^_ 


Fig.  225. — Blood  from  a 
mouse  with  anthrax, 
dried  on  the  cover- 
glass  and  stained  with 
methyl  violet.  Ked 
blootf  corpuscles  and 
anthrax  bacilli,  x  700 
(Kochj. 


Fig.  226.— Anthrax  bacilli  joined  to- 
gether in  the  form  of  threads  from 
a  three  hours'  old  culture  of  the 
blood  of  a  guinea-pig  in  humor 
aqueus,  x  650  (Koch;. 


and  such  spindle- 
shaped  or  tadpole- 
formed  rods  are 
known  as  clastri- 
dia. 

3.  The  Spiral- 
shaped  Bod  Ba- 
cillus {Spirillum). 
— The  spirilla 

(Fig.  227)  have 
the  appearance  of  spirally  twisted  threads  or  fragments  of  cork-screws. 
The  bacterium  which  has  the  twist  but  slightly  marked  is  known  as  a 
vibrio  (Fig.  228). 

Under  each  of  the  separate  classes  of  bacteria  there  are  many  varieties 
and  species  which  are  of  great  importance  from  a  diagnostic  standpoint. 

Thus  there  are  small  or  large,  oval  or  lancet-shaped  cocci,  also 
slender  and  broad  bacilli,  etc.  Within  one  species  differences  occur 
depending  upon  the  condi- 
tions of  nourishment  or  age. 

The  Stmct-iire  and  Repro- 
duction of  Bacteria. — The  Ijac- 
teria,  like  other  vegetable 
cells,  consist  of  an  inner  por- 
tion surrounded  by  an  envel- 
oping membrane.  Their  in- 
terior is  made  up  of  albumi- 
noid matter,  fats,  salts,  and 
water,  while  the  enveloping  membrane  is  probably  allied  to  one  of  the 
cellulose  bodies  belonging  to  the  hydrocarbon  compounds.  C.  Frankel 
and  others  consider  it  doubtful  whether  or  not  a  nucleus  exists  within 
the  protoplasmic  contents  of  these  cells. 

The  bacteria  are  often  surrounded  by  a  gelatinous  enveloping  sub- 
stance, which  facilitates  the  formation  of  the  above-mentioned  bands. 
It  can  in  some  cases  be  made  visible  by  the  usual  staining  materials, 
but  in  others  a  special  treatment  is  necessary  with  iodine. 


Fig.  227. — Spirochaetae  Ober- 
meieri  (spirillum  of  relaps- 
ing fever ).  x  700. 


Fig.  228.— Group  of 
vibrio  serpens,  x 
6-50  (Flutrire). 


260 


INFLAMMATION   AND   INJURIES. 


Fig.  229.— Spirillum 
volutan8,eiich  with 
a  ilagellum  on 
either  end. 


Movements  of  Bacteria. — Many  bacilli  and  s]nrilli  are  capable  of 
active  movement,  and  of  moving  from  one  spot  to  another.  The  micro- 
cocci do  not  possess  the  power  of  locomotion,  but 
are  seen  to  have  only  a  tremulous  molecular  "  BroM'- 
nian  "  movement ;  but  Loffler  and  Mendoza  have  re- 
cently discovered  two  species  of  micrococci  which  do 
have  the  power  of  motion.  The  locomotion  of  the 
bacilli  and  spirilla  which  are  capable  of  motion  is 
brought  about  by  peculiar  organs  called  cilia  or  flagel- 
la.  Loffler  has  recently,  b}'  means  of  a  particular 
method  of  staining,  demonstrated  these  flagella  in  a 
great  many  of  the  important  pathogenic  bacteria. 
The  flagellum  is  found  either  at  one  end  only  or  at 
both  ends  of  the  organism,  and  is  often  very  long 
(Fig.  229).  Other  bacteria,  such  as  the  spirillum  un- 
dula,  possess  at  each  end  not  a  single  flagellum,  but  a  whole  bunch  of 
fine  filaments  all  curved  in  the  same  manner.  R.  Pfeiffer,  with  the 
assistance  of  Loffler's  staining  process,  has  demonstrated  that  many  bac- 
teria, such  as  the  typhoid 
bacilli,  have  their  entire 
periphery  studded  with  fine 
cilia,  causing  them  to  resem- 
ble a  centipede  or  a  spider 
(Fig.  230). 

Reproduction  of  Bacteria. 
— The  bacteria  multiply  by 
division  or  fission  ;  the  cells 
become  somewhat  increased 
in  length,  and  form  two  sep- 
arate and  distinct  individ- 
uals, or  they  remain  adher- 
ent to  each  other  after  di- 
vision (diplococcus,  strepto- 
coccus, vil)rio).  The  mul- 
tiplying power  of  the  fission 
fungi  is  enormous.  If,  as 
Fliigge  says,  the  average  length  of  time  required  for  fission  to  occur 
is  one  hour,  there  will  be  formed  from  each  bacterium  within  twenty- 
four  hours  about  sixteen  million  new  ones.  Bacteria,  such  as  the  ba- 
cillus subtilis,  the  bacillus  anthracis,  and  the  bacillus  megaterium,  prop- 
agate themselves  by  the  formation  of  spores,  which  is  an  actual  fructi- 
fication in  the  interior  of  the  cells — that  is,  by  the   formation  of  a 


Fig.  230.- 


-Typhoid  bacilli  with  numerous  fine 

tiajjella. 


§59.]  MICRO-ORGANISMS.  2G1 

strongly  refracting,  shining  body,  wliich  is  set  free  by  the  atrophy  of 
the  remainder  of  the  cells  (Fig.  231).  Each  cell  only  forms  a  single 
spore.     If  the  spores  find  lodgement  in  a  nutritive  medium,  they  sooner 


I  I «/. 


^ 


Fig.  "231. — Formation  of  spores  in  anthrax  baciUi  (Koch) :  a,  From  the  spleen  of  a  mouse  after 
twenty-four  hours'  cultui'e,  x  650 ;  6,  germination  of  the  spores,  x  650 ;  c,  specimen  h  mag- 
nified 1,650  times. 

or  later  germinate,  and  each  spore  will  develop  into  a  cell  similar  to  the 
mother  cell  from  which  the  spore  originated.  Spore  formation  has 
been  observed  in  various  species  of  bacilli  and  in  some  of  the  spirilla, 
but  hitherto  in  none  of  the  micrococci.  The  bacteria  undergo  spore 
formation  for  the  purpose  of  propagating  the  species,  particularly  when 
at  the  height  of  their  development  and  Avhen  the  conditions  governing 
their  nutrition  and  growth  are  at  the  best.  By  subjecting  the  proto- 
plasm of  the  bacteria  to  certain  injurious  influences  their  power  of 
spore  formation  can  be  temporarily  or  permanently  arrested  (Lehmann, 
Behring,  etc.).  From  a  pathological  standpoint  the  capability  which 
the  spiores  possess  of  withstanding  noxious  influences,  such  as  dryness, 
heat,  cold,  or  chemical  substances,  is  of  great  importance.  The  spores 
of  many  bacteria  can  retain  their  vitality  unimpaired  for  as  much  as  a 
year  when  kept  in  a  dry  condition,  or  even  in  absolute  alcohol.  A  dry 
heat  of  140°  C.  (284°  F.)  destroys  their  power  of  reproduction  with  cer- 
tainty only  after  many  hours,  and  they  can  withstand  boiling  for  several 
minutes.  Globig  had  to  subject  the  spores  of  the  potato  bacillus  to 
the  action  of  steam  for  more  than  four  hours  before  they  died.  This 
great  power  of  resistance  which  spores  possess  is  perhaps  due  to  the 
remarkably  tough  character  of  their  enveloping  membrane.  The 
spores  of  the  different  kinds  of  bacteria  vary  very  much  in  their  capa- 
bilities of  resisting  noxious  conditions. 

Arthrospores.— Besides  the  endospores,  or  those  which  are  formed 
in  the  interior  of  the  cells,  there  are  also  arthrospores.     They  owe 


262  INFLAMMATION   AND   INJURES. 

their  existence  to  the  fact  that  certain  seo-nients  of  a  chain,  strins:,  or 
chister  of  bacteria  have  more  vitality  than  the  others  and  serve  to 
propagate  the  species  after  the  death  of  the  remainder  of  the  bacteria. 
The  arthrospores  liave  no  other  typical  means  of  recognition,  and  they 
are  not  particularly  resistant  to  unfavourable  influences. 

The  occurrence  of  Bacteria  and  the  conditions  suitable  for  their  Life. — 
Bacteria  are  found  everywhere.  The  air,  earth,  water,  and  the  things 
which  they  contain,  our  clothing,  our  food,  skin,  etc.,  support  a  vast 
number  of  these  invisible  living  beings  or  plants,  and  only  the  normal 
organs,  the  blood  and  the  lymph  in  the  healthy  body  of  man  and  ani- 
mals, are  free  from  them.  Bacteria  do  not  originate  by  spontaneous 
generation,  or  generatio  tequivoca — i.  e.,  by  springing  from  molecules. of 
another  kind — but  they  grow  only  from  spores  of  their  own  species 
(Pasteur  and  others).  The  above-described  spores  are  the  principal 
means  for  the  preservation  of  the  various  kinds  of  bacteria. 

From  the  fact  that  bacteria  are  found  almost  everywhere,  it  follows 
that  they  require  but  little  for  their  development ;  the  smallest  amount 
of  organic  material  is  capable  of  supporting  them.  They  require  chiefly 
nitrogen  and  compounds  of  carbon.  The  amount  of  nutritive  matter 
which  the  diiferent  species  need  varies  very  much,  but  in  general  they 
require,  besides  inorganic  material,  food  which  contains  nitrogen  (albu- 
men), or  is  free  from  nitrogen  (sugar,  glycerine).  It  is  very  important 
that  the  nutritive  medium  should  be  alkaline,  or  at  least  neutral  in 
reaction,  as  bacteria,  with  a  few  exceptions,  do  not  grow  in  an  acid 
medium.  The  bacteria  which  grow  exclusively  in  dead  organic  mate- 
rial are  called  the  ohligate  saprophytic,  while  the  obligate  parasitic 
hacteria  are  those  which  only  grow  in  the  living  body  of  a  warm- 
blooded aninial.  But  there  are  a  vast  number  of  bacteria  which 
are  saprophytic  (living  upon  dead  oi'ganic  matter),  and  exist  as  para- 
sites, the  so-called  facultative  parasitic  or  facultative  saprophytic 
fungi. 

Adaptation  of  Bacteria  to  unsuitable  Nutritive  Media. — The  bacteria 
have  the  power  of  adapting  themselves  gradually  to  media  which  are 
unfavourable  to  their  development,  and  are  thus  able  to  accommodate 
themselves  even  to  antiseptic  solutions,  like  bichloride,  when  they  are 
allowed  to  become  gradually  accustomed  to  it.  Trambusti  succeeded, 
in  the  case  of  Friedliinder's  pneumococcus  and  other  bacteria  (the  an- 
thrax bacillus  and  the  staphylococcus  pyogenes  aureus,  etc.),  in  increas- 
ing the  concentration  of  the  bichloride  of  mercury  contained  in  the 
nutritive  bouillon  from  1  to  40,000  up  to  1  to  2,000  without  interfer- 
ing with  their  development.  But  if,  on  the  other  hand,  these  microbes 
were  placed  immediately  in  a  bichloride-bouillon  mixture  of  a  strength 


i;59.]  MICRO-ORGANISMS.  263 

of  I  part  l»iclil()i'i(le  to  ir),(»00  of  Ijouilloii,  tlicir  development  oea.sed 
iiniiicdiately. 

Influence  of  Oxygen. — ()xy<:;en  plavs  a  very  iniportuiit  ])art  in  the 
life  of  bacteria.  J\iany  species  will  only  grow  in  the  presence  of  free 
oxygen  {obligate  aerohic  hacteria),  while*  the  ohligate  anaearobic  bacteria 
will  only  do  so  when  free  oxygen  is  absent  from  their  nutritive  me- 
dium. Other  bacteria — and  they  include  the  majority  of  the  pathogenic 
bacteria — are  facultative  aerobic  and  facultative  anaerobic  ;  i.  e.,  their 
growth  is  not  dependent  on  the  presence  of  oxygen,  though  the  facul- 
tative ai'robic  tiourisli  better '^/vV/i  oxygen,  and  the  anaerobic  witJioid  it. 

Influence  of  Temperature. — Temperature  has  an  important  influence 
upon  them.  A  certain  amount  of  warmth  is,  of  course,  necessary  for 
the  development  of  bacteria  as  well  as  for  any  kind  of  life,  and  each 
species  has  its  own  temperature— that  is,  there  is  a  range  of  tempera- 
ture for  each  species  which  is  best  adapted  for  the  growth  of  that  spe- 
cies. The  saprophytes  are  best  suited  by  the  ordinary  temperature  of 
a  room  (20°  to  25°  0.-68°  to  77°  F.),  the  parasites  by  blood  heat  (35° 
to  40°  C. — 95°  to  104°  F.),  while  other  classes  are  capable  of  growing 
at  temperatures  close  above  the  freezing  point,  and  even  below  it. 
When  the  temperature  is  abnormally  high  or  low  the  bacteria  become 
benumbed  by  the  heat  or  cold,  and  if  the  temperature  rises  or  falls  still 
more  they  perish.  It  is  well  known  that  the  spores  have  a  remark- 
able power  of  resisting  extremes  of  temperature.  The  limits  of  tem- 
perature compatible  with  the  development  of  most  of  them  lie  between 
40°  and  50°  C.  (104°  to  122°  F.) ;  of  others,  between  60°  and  70°  C. 
(150°  to  168°  F.).  The  pus  cocci,  when  in  a  dry  state,  can  retain  their 
vitality  for  a  long  time  at  a  temperature  of  80°  C.  (186°  F.).  Globig 
and  Mirpiel  have  discovered  bacteria  which  can  still  grow  and  multiply 
at  a  temperature  ranging  between  60°  and  70°  C.  (150°  to  168°  F.). 

Influence  of  Light. — Exposure  to  sunlight  has  a  deleterious  effect 
upon  certain  bacteria,  such  as  the  tu])ercle  and  anthrax  bacilli,  which 
die  comparatively  quickly  under  the  direct  action  of  the  sun. 

Influence  of  the  Constant  Electric  Current, — The  constant  electi-ic  cur- 
rent appears  to  have  only  a  slight  or  no  injurious  influence  at  all  upon 
the  development  of  bacteria. 

The  Products  of  the  Life  and  Metabolism  of  the  Bacteria. — By  means 
of  their  vital  activity  the  bacteria  generate  certain  products  of  meta- 
bolism, of  which  some  exert  a  restraining  influence  upon  tlie  gi-owth 
of  the  bacteria;  such  products  are  carbonic  acid,  lactic  acid,  acetic  acid, 
etc. ;  upon  other  species  of  bacteria  the  increasing  alkalinity  of  the  nu- 
tritive medium  acts  unfavourably.  Many  bacteria  generate  ferments  or 
soluble  organic  bodies  which  readily  change  such  complicated  insoluble 


20J:  INFLA.MMATIOX   AND   INJURIES. 

compounds  as  albumen  or  starch  into  soluble  su1)stanees,  acting  in  the 
same  way  as  the  pepsin  or  ptjalin  does  in  animals.  In  many  bacteria 
there  is  a  peptonising  ferment  which  will  liquefy  gelatine,  and  this  is  a 
matter  of  much  importance  for  diagnostic  purposes.  In  fact,  the  vari- 
ous species  of  bacteria  have  been  divided  into  the  general  classes  of 
those  which  liquefy  and  do  not  liquefy  gelatine. 

Toxines  or  Ptomaines. — The  bacteria  are  the  cause  of  all  fermentation 
and  decoraposition.  Pathologically,  there  is  a  very  important  series  of 
poisons  called  toxines,  which  are  a  part  of  the  metabolic,  products  of 
the  bacteria.  Some  of  these  toxines  belong  to  the  organic  bases  result- 
ing from  decomposition  (cadaver  alkaloids  or  ptomaines)  and  some  to 
the  albumens  and  albumenoids  (toxalbumens).  The  toxalbumens  are 
formed  by  the  action  of  the  pathogenic  bacteria  upon  the  albumen  of 
the  affected  tissues.  The  ptomaines — or,  better,  the  toxines — produced 
in  decomposing  matter  have  long  been  known  to  possess  toxic  proper- 
ties. In  1S63,  Panum  isolated  cadaverine  from  this  source,  and  Berg- 
mann  and  Schmiedberg  found  a  crystalline  body  which  they  called 
sepsine.  Selmi  was  the  first  to  name  these  bodies  properly,  calling 
them  ptomaines  or  cadaver  alkaloids,  Nencki  was  the  first  to  obtain 
one  of  them  in  a  pure  state— collidin — and  thus  to  ascertain  its  composi- 
tion. Brieger  and  others  experimented  with  ptomaines,  or  rather  tox- 
ines, and  obtained  from  cultures  of  bacteria  many  toxines  in  a  pure  state, 
such  as  peptotoxine,  neurine,  neuridine,  choline,  etc.,  and  extremely 
poisonous  toxines  from  cultui*es  of  cholei*a,  typhoid,  and  tetanus  bacilli. 
Their  highly  toxic  character  was  demonstrated  by  inoculations  upon 
animals.  Many  ptomaines  or  toxines  have  an  effect  similar  to  mor- 
phine, curare,  or  atropine.  Peptotoxine  causes  death  in  the  animals  ex- 
perimented upon  with  symptoms  of  paralysis;  and  neurin.  according  to 
Brieger,  acts  like  muscarine,  causing  salivation,  contraction  of  the  pu- 
pils, disturbances  of  respiration  and  circulation,  and  chronic  spasms* 
This  explains  the  general  systemic  poisoning  of  various  kinds  due  to 
bacterial  infection  of  wounds,  and  in  part  the  cases  of  poisoning  caused 
by  ingestion  of  decomposing  food  with  the  ptomaines  it  contains  (meat, 
sausage,  milk,  and  cheese  poisoning).  The  toxines  can  be  separated 
from  the  bacteria  by  filtration  through  porcelain,  and  then,  by  inject- 
ing the  toxines  beneath  the  skin  of  animals,  it  is  possible  to  study  their 
poisonous  manifestations,  such  as  severe  gastro-enteritis,  nervous  dis- 
turbances, cramps,  etc.  If  cultures  of  bacteria  are  subjected  to  a  tem- 
perature of  60°  C,  the  micro-organisms  will  perish,  and  the  poisonous 
effects  of  many  of  the  ptomaines  can  be  studied,  but  the  toxalbumens 
will  have  been  destroyed.  The  nature  and  composition  of  the  nutri- 
tive medium  plays  an  important  part  in  the  formation  of  the  toxines 


§59.]  MICRO-ORGANISMS.  2C5 

produced  by  any  particular  kind  of  bacteria— i.  e..  the  same  bacteria 
do  not  under  all  circumstances  produce  the  same  toxines.  Even  harm- 
less bacteria,  like  the  micrococcus  prodigiosus,  may,  when  combined 
with  some  second  species  also  non-pathogenic,  become  dangerous  to  the 
animal  economy.  The  specific  poisons  of  many  bacteria — for  exam])Je, 
the  tubercle  bacilli — are  not  found  in  the  nutritive  medium,  but  chiefly 
in  the  bodies  of  the  bacteria  themselves,  so  that  tuberculosis  can  be 
excited  by  dead  tubercle  bacilli  (R.  Koch,  Prudden,  Hodenpyl,  etc.). 
It  was  long  ago  demonstrated  by  Buchner  that  poisonous  proteijis 
which  are  capable  of  exciting  inflammation  are  very  apt  to  be  present 
in  the  bodies  of  the  bacteria.  Buchner,  Lange,  and  F.  Roemer  pointed 
out  that  these  poisonous  bacterial  proteins  have  a  gi'eat  power  of  at- 
traction for  the  leucocytes  (chemotaxis),  and  after  intravenous  in- 
jection cause  an  increase  in  the  number  of  the  leucocytes  (leucocy- 
tosisi. 

Pigment  Formation. — Many  bacteria  form  colouring  matter  (Fig.  232) 
of  many  different  shades,  such  as  white,  black,  red,  blue,  green,  and 
brown,  giving  to  the  culture,  and  often 
to  a  great  part  of  the  nutritive  medium, 
a  characteristic  tinge.  The  pigment 
l)acteria,  in  all  probability,  possess  a 
cliromogenic  body,  which  when  exposed 
to  the  influence  of  oxygen  changes  to  a 
colouring  matter. 

Phosphorescence. — Many  bacteria  are 
phosphorescent — i.  e.,  they  are  luminous 
in  the  dark  (Fischer). 

Products   of    the    Bacteria  —  Different      ^  ^     ,   . 

Tfiv    i      J?  ^-L     T.     J      J.  .    T    •  1  /",  Fig.  2.3'2. — Staphvlococcus  pyogenes 

iiiiects  01  the  Products.— Ai-lomg  and  Cour-  citreus,  potato  culture. 

mont  distinguish  three  principal  classes  of 

the  prodixcts  of  the  pathogenic  bacteria  :  1.  The  substances  precipitable  by 
alcohol  ^diastases),  by  acidified  alcohol  (toxalbumens),  by  Millon's  reagent 
(peptones).  Diastases  and  toxalbumens  are  capable  of  dialysis  only  to  a  slight 
extent.  2.  The  substances  which  are  soluble  in  alcohol  and  ether  and  can  be 
precipitated  by  acetate  of  lead  and  bichloride  of  mercury  are  dialysable  and 
are  but  slightly  altered  by  heat  (ptomaines,  alkaloids).  3.  The  volatile  sub- 
stances, coloured  compounds  of  carbon,  etc.  Some  of  the  products  have 
toxic,  some  predisposing,  and  some  immunifying  properties,  and  they  have 
all  been  Isolated  from  various  species  of  bacteria  (Behring,  Fi'ankel,  Ro- 
vet.  etc.). 

'  The  marasmus  accompanying  acute  and  chronic  disea.ses  due  to  bacterial 
infection  is  caused  by  the  products  of  the  metabolism  of  the  bacteria,  as  Man- 
netti  has  proved  in  the  case  of  the  metabolic  products  of  the  staphylococcvis 
pyogenes  aureus  and  albus. 


266  INFLAMMATION   AND   INJURIES. 

The  Limitations  to  the  Growth  of  Bacteria ;  their  Death.— Yarious 
influences  place  restraints  upon  the  growth  of  the  bacteria,  such  as  too 
low  or  too  high  temperatures,  absence  of  water,  the  addition  of  certain 
chemical  substances  or  bacterial  poisons  to  their  nutritive  medium,  etc. 

If  noxious  influences  are  not  permitted  to  act  too  intensely  upon 
the  bacteria  the  latter  become  weakened,  and  this  weakening  process 
can  be  kept  up  through  several  generations,  causing  the  pathogenic 
species  to  lose  their  virulence  partially  or  completely.  Cultures  of 
bacteria  which  have  been  thus  weakened  have  often  been  employed 
for  inoculating  purposes  as  a  prophylactic  measure  against  infectious 
diseases. 

If  the  above-mentioned  noxious  influences  are  permitted  to  act  too 
intensely  or  too  long  the  bacteria  will  finally  die.  It  is  possible  to  kill 
bacteria  by  a  great  number  of  chemical  substances,  the  chief  of  which 
are  our  commonly  used  antiseptics,  bichloride  of  mercury  and  carbolic 
acid,  provided  they  are  employed  in  sufticiently  concentrated  solutions. 
Bacteria  may  also  be  destroyed  by  insufficient  nourishment,  by  depri- 
vation of  water,  by  exposure  to  the  direct  rays  of  the  sun,  or  by 
other  antagonistic  bacteria  or  the  products  of  their  metabolism  (acids, 
alkalies),  and  especially  by  abnormally  low  or  high  temperatures,  rang- 
ing from  50°  to  80°  C.  (122°  to  176°  F.)  and  higher.  As  we  have  said 
before,  low  temperatures  are  less  injurious,  as  a  general  thing,  than  ab- 
normally high  temperatures.  Many  of  those  bacteria  which  do  not 
form  spores,  and  the  majority  of  the  kinds  which  do,  are  capable  of  re- 
taining their  vitality  in  ice.  The  spores  are  also  very  resistant  to  high 
grades  of  temperature,  ranging  between  50°  and  80°  C.  In  general, 
they  are  killed  only  at  a  temperature  of  100°  C,  some  of  them  needing 
to  be  subjected  to  it  from  two  to  ten  minutes,  and  others  several  hours. 
Budding,  sprouting  spores  are  more  rapidly  killed  than  those  which 
have  not  budded.  The  most  effective  manner  of  destroying  bacteria  is 
by  subjecting  them  to  boiling  water  or  hot  steam.  Dry  heat,  at  a  tem- 
perature of  140°  to  160°  C.  (284°  to  320°  F.),  requires  three  hours  to 
kill  bacteria,  while  boiling  water  or  steam  only  requires  from  five  to 
ten  minutes.  According  to  Tassinari,  tobacco  smoke  has  a  decided  bac- 
tericidal power. 

Tests  and  Comparisons  of  the  Germicidal  Substances.— The  efficacy  of  a 
germicide  is  tested  by  inoculating  the  bacterial  matter  previously  subjected 
to  its  influence  upon  living  animals  and  observing  whether  or  not  infection 
follows,  or  fresh  moist  or  dried  colonies  may  be  placed  upon  glass  slides,  silk 
threads,  grains  of  sand,  etc.,  and  thus  brought  into  contact  for  a  certain 
length  of  time  with  the  germicide  that  is  to  be  tested.  The  colonies  thus 
treated  are  then  placed  in  some  nutritive  medium,  such  as  gelatine  or  bou- 


§59.]  .  MICRO-ORGANISMS.  207 

illon,  and  kept  at  a  teiiiperatui*e  of  l?5°  C.  (77°  F.).  If  chemical  substances  are 
to  be  tested,  the  glass  slides  or  threads,  etc.,  must  first  be  washed  in  sterilised 
distilled  wate)-  to  prevent  them  from  carrying  any  of  the  poison  into  the 
nuti'itive  gelatine,  and  consequently  restraining  the  growth  of  the  bacteria. 
After  the  cultures  have  been  kept  at  the  proper  tempei'ature  for  several  days, 
and  have  shown  no  develo])nient  of  colonies  of  bacteria,  it  may  be  inferred 
tliat  the  previously  existing  organisms  have  been  killed  by  the  substance  in 
question. 

Ordinary  Methods  of  studying  Bacteria.— The  bacteriological  methods  of 
investigation  consist  ])rincipally  in  the  study  of  stained  ])reparalions  under 
the  microscope,  and  in  experiments  with  cultivation,  and  in  reinoculation  of 
the  artificially  cultivated  bacteria  upon  living  animals.  The  microscopical 
part  of  the  investigation  of  bacteria  has  been  greatly  advanced  by  Robert 
Koch,  who  showed  the  necessity  of  homogeneous  immersion  and  the  proper 
way  of  using  Abbe's  condenser  or  illuminating  apparatus.  The  basic  aniline 
dyes  are  the  best  materials  for  staining  both  the  bacteria  and  the  cell  nuclei. 
We  employ  aqueous  solutions  of  gentian  violet,  fuchsin,  and  especially 
methylene  blue,  made  in  the  last  instance  by  thirty  centimetres  of  a  concen- 
trated alcoholic  solution  of  methylene  blue,  one  hundi'ed  centimetres  of  water, 
and  twenty  di*ops  of  a  one-per-cent.  caustic-potash  solution.  If  it  is  desired 
to  rfltike  a  prepai-ation  rapidly  from  a  fluid  containing  bacteria,  a  drop  of  the 
liquid  is  evaporated  upon  a  cover-glass.  The  residue  is  fixed  by  i)assing  the 
cover-glass  three  times  through  the  flame  of  a  Bunsen  burner,  and  then 
placing  it  for  a  few  minutes  in  one  of  the  above-mentioned  staining  solu- 
tions— methylene  blue,  for  example.  The  excess  of  colouring  matter  is  then 
washed  from  the  cover-glass  with  distilled  water,  the  specimen  placed  upon 
a  slide  and  exanjined  in  the  bright  light  provided  by  the  Abbe  condenser, 
with  or  without  a  blender.  The  importance  of  the  Abbe  condenser  lies  in 
the  fact  that  it  brings  into  prominence  the  coloiu^ed  portions  of  the  stained 
preparation,  especially  the  nuclei  and  the  bacteria.  When  unstained  objects 
are  to  be  examined  the  use  of  the  condenser  is  to  be  restricted— i.  e.,  a  nar- 
row blender  is  to  be  used,  and  less  light  allowed  to  fall  upon  the  slide.  In 
examining  with  the  microscope  fluids  containing  bacteria,  it  is  a  good  plan 
to  use  hollowed-out  slides.  For  the  recent  methods  of  staining  bacteria  I 
must  refer  the  reader  to  the  text-books  of  Frankel,  Hueppe,  Gunther,  Eisen- 
berg.  and  others. 

Culture  Methods— The  Various  Kinds  of  Culture  Media.— By  artificial 
cultures  of  bacteria,  and  their  subsequent  inoculation  upon  animals,  our 
knowledge  of  the  effects  produced  by  bacteria  has  been  very  much  advanced. 
Bacteria  are  cultivated  partly  in  liquid  and  partly  in  solid  nutritive  media. 
The  vessels  for  conducting  the  experiments  are  exposed  to  dry  heat  at  a  tem- 
perature of  160°  C,  in  a  sterilising  apparatus,  for  from  one  to  two  hours, 
while  the  nutritive  media  are  sterilised  in  advance  in  a  Papin's  digester,  or 
by  steam,  in  order  to  kill  the  bactei'ia  which  may  already  be  existing  in  them. 

The  fluid  nutritive  media  (infusion  of  meat,  infusion  of  hay,  milk,  urine, 
blood  serum,  etc.)  are  inferior  in  every  respect  to  the  translucent  solid  media 
(gelatine,  agar-agar).  In  the  liquid  media  it  is  possible  to  watch  the  growth, 
increase,  and  finally  the  spore  formation,  by  means  of  "cultures  in  hanging 
drops. "   With  the  aid  of  a  sterilised  platinum  wire  hook  a  drop  of  the  sterilised 


268  INFLAMMATION  AND  INJURIES. 

nutritive  liquid  is  placed  upon  a  cover-glass  which  has  jiist  been  heated;  to 
the  drop  is  then  added  a  very  small  amount  of  the  culture.  A  concave  glass 
slide  is  sterilised  by  heat,  vaseline  placed  around  the  concavity,  and  the  cover- 
glass  laid  upon  the  vaseline  circle,  with  the  drop  of  nutritive  liquid  dipping 
into  the  concavity.  The  solid  nutritive  media  (gelatine,  agar-agar)  become 
fluid  at  temperatures  between  25''  and  30°  C.  and  35°  and  40°  C,  respectively, 
but  solidify  rapidly  on  cooling.  If  bacteria  are  planted  in  the  most  com- 
monly used  nutritive  gelatine  (bouillon,  eight  per  cent,  gelatine,  one  per  cent, 
peptone,  one-half  per  cent,  common  salt),  which  has  been  heated  to  a  temper- 
ature of  30°  C  in  a  test  tube,  and  so  liquefied,  and  if  the  well-mixed  fluid  is 
then  poured  upon  sterilised  glass  plates  or  saucers,  the  bacteria  will  grow  in 
the  rapidly  hardening  gelatine,  and  after  the  lapse  of  one  or  two  days  will 
form  visible  cultures.  The  microscope  shows  that  each  colony  is  made  up 
of  individuals  of  the  same  species.  To  prevent  the  colonies  from  growing 
too  thickly,  it  is  best  to  dilute  the  gelatine  first  infected,  and  to  pour  the  di- 
luted liquid  upon  a  larger  number  of  glass  plates,  a  portion  of  the  nutritive 
medium  in  the  first  glass  being  emptied  into  a  second,  to  which  gelatine  is 
then  added,  and  this  last  fluid  is  then  mixed  with  more  gelatine  in  still  a  third 
glass.  All  the  mixtures  are  then  poured  into  a  little  shallow  glass  dish.  The 
agar  mixture,  which  remains  solid  up  to  a  teinjierature  of  38°  C,  is  employed 
for  bacteria  requiring  a  temperature  higher  than  25°  C  It  is  thus  possible 
to  make  cultures  of  any  desired  species  of  bacteria  in  a  solid  medium.  The 
cut  surfaces  of  slices  of  a  boiled  potato  are  also  much  used  as  a  solid  nutritive 
medium,  and  distinct  colonies  can  be  made  to  grow  upon  them  by  spreading 
out  over  the  surface  of  the  potato  thus  prepared  a  single  drop  of  liquid  con- 
taining three  or  four  species  of  bacteria.  Under  pi'oper  conditions  every 
bacterium  will  then  develop  into  a  separate  colony. 

The  different  species  of  bacteria  require  particular  kinds  of  nutritive 
media — blood  serum,  for  instance — while  other  species  must  have  media 
which  do  not  contain  oxygen.  The  latter  requirement  is  obtained  by  a  thick 
layer  of  gelatine  or  agar,  or  by  supplanting  the  air  in  the  culture  vessel  by 
hydrogen  gas,  or  by  the  addition  of  reducing  substances  (one  to  two  per  cent, 
dextrose,  formate  of  sodium,  pyrocatechin,  etc.).  A  number  of  known  bac- 
teria have  as  yet  eluded  all  attempts  at  cultivation.  The  behaviour  of  the 
cultures  in  the  nutritive  media,  such  as  gelatine  or  agar,  can  now  be  watched 
very  exactly.  Some  species,  for  example,  form  dry  white  masses,  others 
white  slimy  drops,  and  still  other  colonies  liquefy  the  gelatine,  or  develop 
into  colonies  having  a  bright  red,  yellow,  or  green  colour,  etc. 

If  a  cover-glass  placed  upon  the  gelatine  plate  is  pressed  lightly  on  the 
colonies  growing  upon  the  surface,  and  then  lifted  off,  a  portion  of  the  colo- 
ny will  cling  to  the  glass.  This  cover-glass  preparation  is  then  passed  three 
times  slowly  through  the  Bunsen  flame,  treated  with  a  drop  of  fuchsin  or 
gentian  violet,  washed  with  water,  and  examined  under  the  microscope. 

Needle-point  Cultivation.— The  needle-point  cultures  are  especially  im- 
portant (Fig.  233),  and  are  made  in  the  following  manner:  A  platinum  wire 
is  brought  into  contact  with  some  particular  colony  of  bacteria,  and  then 
plunged  into  nutritive  gelatine  contained  in  a  glass  test-tube.  In  the  region 
of  the  puncture  the  characteristic  ciilturc  will  develop. 

Linear  Cultures. — When  a  linear  culture  is  made  the  gelatine  is  allowed 


S59.I 


MICRO-ORGANISMS. 


269 


<& 


ill  I  „/ 1 


to  harden,  so  that  its  surface  forms  a  plane  obliquely  directed  towards  the 
sides  of  the  test  tube,  and  over  this  surface  is  lightly  drawn  the  platinum 
wire  which  carries  the  bacteria. 

Of  course  care  must  be  taken  in  both  the  needle-point  and  linear  cultiva- 
tions that  only  the  particular  species  of  bacteria 
to  be  investigated  is  introduced.  /#^i#^^*-^  v  "'     -'  '"\ 

These  few  general  remarks  on  the  methods     i^i     *       Pi        f  -n 

of  investigation  pursued  in  bacteriology  will 
suffice  for  our  purpose.  More  detailed  desci'ip- 
tions  can  bo  had  by  reference  to  the  text-books 
of  C.  Friinkcl,  Fliigge,  Hueppe,  and  others. 

The  Action  of  Pathogenic  Bacteria — Meth- 
ods of  Transmission,  and  Experimental  Inocu- 
lation of  Animals. — The  l)oiiiKlaries  between 
the  noxious,  disease-producing  or  pathogenic 
bacteria  and  the  non-pathogenic  are  not  very 
sharply  defined.  Even  non-pathogenic  bac- 
teria can  under  certain  conditions,  as  before 
remarked,  do  a  great  deal  of  harm,  while,  on 
the  other  hand,  even  virulentlj^  pathogenic 
micro-organisms  ma}'  in  various  ways,  such 
as  by  peculiar  methods  of  cultivation,  be 
rendered  weak  or. entirely  inert  (see  page 
266). 

How  do  the  pathogenic  bacteria  act? 
The  pathogenic  bacteria  produce  their  nox- 
ious effects,  in  the  first  place,  by  forming 
specific,  extremely  poisonous  products  of 
metabolism  (toxines,  ptomaines,  toxalbu- 
mens,  etc.)  which  damage  the  animal  organ- 
ism in  a  definite  way.  Other  species  of  bacteria  become  dangerous  to 
the  animal  ecotiomy  on  account  of  their  great  numbers.  They  in- 
crease with  great  rapidity  and  spread  throughout  the  body,  as  is  the 
case  with  the  anthrax  bacilli,  which  in  a  purely  mechanical  way  produce 
very  serious  changes  in  the  different  organs,  and  prove  fatal  by  con- 
suming the  nutritive  matter,  albuminous  substances,  and  oxygen,  which 
are  necessary  to  the  life  of  the  organism. 

Toxic  and  Infectious  Bacteria. — The  first  class  of  bacteria  are  the 
toxic,  the  second  are  the  infectious.  The  toxic  bacteria  form  their 
poisons  outside  of  the  body  only,  and  are  incapable  of  developing  inside 
the  living  body.  If  they  gain  access  in  suflicient  numbers  to  poison 
the  body  they  are  carried  to  all  the  different  organs  by  the  circulating 
blood,  and  can  be  perhaps  demonstrated  in  them  here  and  there ;  but 


A 

Fig.  233. — J,  stab  or  puncture 
culture  ;  B^  linear  culture. 


270  INFLAMMATION   AND   INJURIES. 

their  presence  is  of  secondary  importance,  as  the  main  thing  is  tlie  poi- 
son which  they  have  produced,  upon  tlie  kind  and  amount  of  which 
the  disease  depends.  Cultures  of  the  toxic  bacteria,  whether  Hving  or 
not,  will,  when  inoculated  in  animals,  poison  them.  The  infectious 
bacteria,  on  the  other  hand,  possess  the  power  of  multiplying  within 
the  organism  in  which  they  find  lodgment,  and  of  spreading  them- 
selves through  it ;  and  even  though  very  few  in  number  when  first 
introduced,  they  can  increase  with  incredible  rapidity,  flooding,  as  it 
were,  all  the  organs  of  the  body.  The  anthi-ax  bacillus  is  a  good  ex- 
ample of  this  variety  (see  §  77).  Hand  in  hand  with  the  increase  in 
the  number  of  the  micro-organisms  goes  an  increased  formation  of  the 
poisonous  products  of  their  metabolism,  leading  to  intoxication  (poison- 
ing) of  the  body.  The  original  infection  may  be  produced  by  the  en- 
trance into  the  body  of  an  exceedingly  small  number  of  microbes. 
The  same  species  of  bacteria  may  prove  infectious  for  one  kind  of  ani- 
mal but  not  for  another ;  but  by  feeding  an  animal  in  a  certain  way,  or 
by  subjecting  a  particular  species  of  bacteria  to  proper  cultivation,  the 
animal  may  be  rendered  susceptible  or  not  to  the  particular  species  of 
bacteria.  The  glanders  bacillus  has  an  exceedingly  virulent  effect  upon 
field-mice,  but  white  mice  are  not  affected  by  it.  If,  however,  the 
white  mice  are  fed  upon  phoridzin  until  they  become  diabetic,  they 
change  and  are  then  susceptible  to  this  bacillus.  According  to  Ar- 
loing's  statement,  the  bacilli  of  malignant  oedema  become  infectious 
for  such  animals  as  are  ordinarily  not  affected  by  them  if  the  animals, 
previous  to  their  inoculation,  are  soaked  in  a  twenty-per-cent.  solution 
of  lactic  acid,  or  if  their  tissues  are  first  treated  with  pyrogallic  or  car- 
bolic acids,  or  bichloride  of  mercury. 

Attenuation  of  the  Virulence  of  Bacteria. — It  has  hitherto  been  im- 
possible to  effect  a  lasting  or  permanent  increase  in  the  virulence  of 
the  bacteria,  or  lo  change  the  toxic  bacteria  into  the  infectious  class,  or 
vice  versa ,'  but,  on  the  other  hand,  a  lasting  attenuation  and  even  a 
total  destruction  of  their  virulence  is  possible,  as  in  the  case  of  the 
bacilli  of  chicken  cholera  and  anthrax,  the  pneumococci,  etc.  (Pasteur, 
Toussaint).  This  attenuation  of  the  virulence  of  pathogenic  bacteria 
may  be  brought  about  in  a  natural  as  well  as  in  an  artificial  way.  The 
natural  attenuation  will  take  place,  as  demonstrated  by  Fliigge's  experi- 
ments, in  such  infectious  l)acteria  as  are  compelled  to  grow  for  a  long 
time  under  conditions  differing  from  those  governing  their  ordinary 
existence  and  development,  such  conditions  being  represented  by  arti- 
ficial nutritive  media  or  atmospheric  surroundings  to  which  they  are 
not  accustomed.  By  causing  certain  bacteria  to  accommodate  them- 
selves to  growth  upon  dead  substances — that  is,  giving  them  a  sapro- 


tir,9.]  MICRO-ORGANISMS.  271 

phytic  method  of  life — tlieir  capability  of  developing  in  the  animal 
organism  is  lost.  A  similar  loss  of  specific  action  can  be  produced  in 
saprophytic  bacteria  by  cultivating  them  under  altered  conditions 
(Iluep])e  and  others).  The  virulence  of  bacteria  can  also  be  modified, 
and  even  permanently  abolished,  by  subjecting  them  to  various  influ- 
ences which  are  injurious  to  them.  The  poisonous  character  of  an- 
thrax bacilli  has  thus  been  rendered  weaker  or  destroyed  by  cultivation 
of  the  organisms  in  antiseptic  or  disinfecting  nutritive  media,  such  as 
bouillon  containing  bichromate  of  potassium  (1  to  2,000-5,000),  or 
blood  containing  one  per  cent,  of  carbolic  acid,  or  by  cultivation  under 
a  pressure  of  eight  atmospheres,  or  by  exposure  of  the  culture  to  the 
direct  rays  of  the  sun.  Likewise,  by  breeding  a  special  species  of  bac- 
teria several  times  in  animals  which  are  not  susceptible  to  it,  the  viru- 
lence of  this  species  can  be  diminished.  The  surest  and  most  usual 
way  of  "attenuating  their  virus"  is  the  cultivation  of  bacteria  in  high 
temperatures ;  and  the  lower  the  temperature  that  one  uses  for  bring- 
ing this  about  the  longer  the  process  of  attenuation  will  take,  but  it 
becomes  just  so  much  the  more  permanent,  so  that  the  weakened  poi- 
sonous character  of  the  bacteria  is  transmitted  to  their  offspring,  and 
in  this  way  it  is  possible  to  make  a  series  of  completely  attenuated  cul- 
tures. The  attenuated  differ,  in  all  probability,  from  the  virulent  bac- 
teria in  possessing  a  degenerated  protoplasm,  a  defective  vitality,  a 
diminished  power  of  growth,  less  ability  to  withstand  injurious  influ- 
ences, and  especially  in  having  different  products  of  metabolism.  Viru- 
lent anthrax  bacilli,  for  example,  form  a  greater  amount  of  acid  than 
the  attenuated  ones.  Therefore,  bacteria  which  have  been  attenuated 
or  weakened  do  not  flourish  in  the  animal  system,  as  they  are  incapable 
of  overcoming  its  natural  oppositions  or  hindrances  to  their  growth, 
and  they  die  relatively  quickly  either  at  the  point  of  infection,  or  in 
the  blood,  and  especially  in  the  organs  where  they  are  deposited  by  the 
blood — viz..  the  liver,  spleen,  and  marrow  of  the  bones. 

Power  possessed  by  the  Animal  Organism  of  protecting  itself  against 
Bacteria. — The  healthy  animal  or  human  body  possesses  various  means 
of  protecting  itself  against,  the  entrance  of  bacteria.  The  serum  of  the 
blood,  particularly  if  free  from  cellular  elements,  has  a  direct  germi- 
cidal power,  as  has  been  demonstrated  by  the  beautiful  experiments  of 
Buchner,  Xiessen,  Stern,  and  others.  This  germicidal  power  is  con- 
fined exclusively  to  the  plasma,  while  the  cellular  elements,  the  red  and 
white  blood-cells,  are  antagonistic  to  it.  The  germicidal  power  of  the 
blood  in  a  given  individual  appears  to  have  a  different  intensity  at  dif- 
ferent times.  According  to  H.  Buchner,  it  is  dependent  upon  the 
proportion  of  salts  it  contains.     Fodor  says  that  the  germicidal  power 


272 


INP^LAMMATIOX    AND    INJURIES. 


of  the  blood  i.s  increased  as  it.s  temperature  is  raised  and  as  it  becomes 
more  alkaline  bv  the  addition  of  alkaline  substances.  At  a  tempera- 
ture of  38°  to  40°  C.  (100-4°  to  104°  F.)  the  germicidal  action  of  the 
blood  is  greatest,  but  above  40°  C.  (104°  F.)  it  rapidly  decreases.  At  all 
events,  it  is  mainlj  by  chemical  processes,  if  we  leave  out  of  considera- 
tion the  local  anatomical  peculiarities,  that  the  animal  organism  protects 
itself  against  the  entrance  of  bacteria.  Up  to  a  certain  point  there  is 
also  a  conflict  between  the  bacterial  cells  and  the  cells  in  the  body  of 
the  animal.  According  to  Metschnikoff,  it  is  principally  the  white 
blood-cells  which  take  up  and  devour  the  bacteria  (Fig.  2o4j,  and  for 
this  reason  he  has  called  them  devouring  cells — phagocytes — and  to  them 
he*  ascribes  the  most  important  part  in  the  battle  of  the  system  with 

the  bacteria  which 
have  entered  it.  This 
phagocyte  theory  of 
Metschnikoff's  has  re- 
cently been  successful- 
ly attacked  by  Fliigge, 
Baumgarten,  and  oth- 
ers. The  consensus  of 
opinion  at  present  is 
that,  contrary  to 
Metschnikoff's  idea, 
the  white  blood-corpuscles  are  the  ones  which  succumb  in  the  conflict 
with  the  bacteria,  if  the  latter  enter  the  corpuscles  in  a  living  condi- 
tion, and  only  dead  bacteria  are  carried  away  by  the  cells  of  the  body. 
In  addition,  the  bacteria  are  carried  away  chiefly  in  the  excretions, 
especially  in  the  f.Tces.  urine,  saliva,  and  sweat  fBrnnncr.  Eiselsberg"). 

Natural  or  acquired  Immuaity  of  Animals  and  Man  towards  Bacteria. 
— The  existence  of  immunity  in  man  or  animals  towards  this  or  that 
species  of  bacteria  is  a  matter  of  great  practical  importance.  It  is 
in  part  hereditary  and  in  part  artiticially  acquired.  "We  know  that, 
owing  to  .Tenner's  discovery  of  the  last  century,  man  can  be  made  to 
lose  his  susceptibility  to  variola  by  means  of  the  inoculation  with  cow- 
pox  virus.  The  d^coveries  of  Pasteur  are  in  harmony  with  this 
important  fact — namely,  that  by  inoculation  of  a  weakened  bacterial 
poison  the  system  is  rendered  non-susceptible  to  infection  by  the 
poison  of  such  diseases  as  hydropholjia,  anthrax,  chicken  cholera,  etc. 
Though  Koch,  Loffler  and  others  have  demonstrated,  as  regards 
anthrax,  that  inoculation  with  the  weakened  or  attenuated  anthrax 
poison  provides  no  certain  and  absolute  protection  against  this  disease, 
yet  scientifically  and  practically,  the  fact  remains  established  that  the 


Fig.  234. — Phagocytes  (Metschnikoif ).  a,  an  anthrax  bacillus 
about  to  enter  a  white  blood  corpuscle;  b,  the  anthrax  ba- 
cillus within  the  white  blood  corpuscle:  c,  white  blood  cor- 
puscle with  anthrax  bacilli  which  have  become  broken  into 
pieces. 


§59.]  MICRO-ORGANISMS.  273 

animal  system  can  under  certain  circumstances,  by  inociilati(jn  with  the 
attenuated  bacterial  poison,  be  made  unsusceptible  to  the  most  virulent 
sul)stances — in  other  words,  the  system  becomes  artiticially  immune. 
The  active  principles  of  the  substances  used  in  inoculation  or  vaccination 
are  chemical  bodies,  or  the  products  of  the  metabolism  of  the  bacteria 
themselves.  Numerous  hypotheses  have  been  advanced  for  the  ex- 
planation of  this  acquired  immunity.  Pasteur,  Klebs  and  others  hold 
that  it  depends  upon  the  fact  that  during  the  first  invasion  a  quantity 
of  substances  are  consumed  which  are  essential  to  the  life  of  the  bacteria 
in  (juestion  (exhaustion  theory).  Chauveau  believes,  on  the  contrary, 
that  during  the  first  invasion  of  the  bacteria  metabolic  ]>roducts  form 
from  them,  which  remain  behind  and  make  it  impossible  for  infection 
to  occur  from  the  same  species  (retention  hypothesis).  ]\Ietschnikoff 
employs  his  phagocyte  theory  for  explaining  acquired  imnuinitj'.  C. 
Friinkel  is  probably  right  in  saying  that  the  acquired  toleration  of  a 
poison,  or  immunity,  is  not  a  single  process,  but  is  brought  about  now 
in  this  way  and  now  in  that.  It  is  possible  that  the  exhaustion  or  re- 
tention hypothesis,  or  Metschnikoii's  cell  theory,  or  the  chemical  action 
of  the  blood  and  tissue  fluid,  all  pla}-  an  important  part,  but  we  are 
not  yet  sufficiently  familiar  with  all  the  facts  which  bear  upon  this 
question  to  answer  it  definitely. 

Great  interest  attaches  to  the  experiments  of  AVooldridge,  Kitasato 
and  Behring  upon  the  artificial  production  of  imumnity  towards  an- 
thrax, tetanus,  and  diphtheria.  AVooldridge  discovered  that  solutions  of 
fibrinogen,  after  having  served  as  media  for  the  cultivation  of  anthrax, 
made  an  animal  immune  to  infection  from  anthrax  ;  but,  on  the  other 
hand,  he  obtained  this  immunity  by  producing  a  slight  chemical  altera- 
tion in  the  fibrinogen,  without  making  use  of  the  anthrax  bacilli. 
Behring  and  Kitasato  made  rabbits  immune  towards  tetanus  by  means 
of  trichloride  of  iodine.  Behring  rendered  animals  unsusceptible  to 
diphtheria  by  (1)  employing  cultures  which  were  sterilised  or  had  been 
treated  with  trichloride  of  iodine  ;  (2)  by  the  subcutaneous  and  intra- 
abdominal injection  of  the  pleuritic  exudate  which  frequently  develops 
in  animals  which  have  diphtheria,  and  also  by  the  subcutaneous  injec- 
tion of  the  trichloride  of  iodine  very  soon  after  the  diphtheritic  infec- 
tion. The  capability  of  animals  for  resisting  diphtheria  was  rendered 
greater  by  the  use  of  hydrogen  peroxide.  The  blood  of  such  immune 
animals  possesses  the  power  of  destroying  the  poison  of  the  disease, 
and  consequently  their  serum  has  been  used  for  subcutaneous  injection 
in  cases  of  diphtheria  and  tetanus  in  man,  but  hitl;erto  with  doubtful 
results. 

Acquired  immunity  has  a  very  close  relationship  with  the  recovery 


274  INFLAMMATION   AND   INJURIES. 

from  infectious  diseases.  The  latter  would  not  be  so  difficult  if  the 
germicidal  substances  which  are  known  to  us  had  the  same  effect  in  the 
body  as  in  the  test  tube ;  but  such  is  not  the  case.  In  all  probability 
the  antagonism  existing  between  many  species  of  bacteria  plays  an  im- 
portant part  in  recovery  from  an  infectious  disease.  For  instance,  the 
bacillus  fluorescens  putridus  is  a  pronounced  antagonist  to  the  cocci 
of  suppuration  and  the  bacillus  of  ])neumonia  and  typhoid,  and  if  this 
bacillus  is  implanted  in  gelatine,  the  latter  becomes  incapable  of  infec- 
tion by  the  above-mentioned  organisms.  Emmerich  was  able  to  save 
rabbits  inoculated  with  anthrax  from  sure  death  by  placing  in  their 
blood-vessels,  either  before  or  after  the  anthrax  infection,  a  large  num- 
ber of  the  erysipelas  cocci  or  of  the  micrococci  prodigiosi  or  of  the 
bacilli  pyocyanei.  The  animals,  however,  were  not  rendered  immune 
to  a  second  infection  of  anthrax. 

Technique  of  Experimental  Transmission  of  Bacteria  from  Animal 
to  Animal. — Under  the  heading  of  pathogenic  bacteria  which  have  a 
specific  importance,  we  class  those  which  are  capable  of  demonstration 
in  all  cases  of  any  particular  disease,  and  in  no  other  disease,  and  are 
present  in  such  numbers  and  have  such  a  distribution  in  the  tissues  that 
they  readily  account  for  all  the  symptoms  of  this  particular  disease. 
The  certainty  of  the  specific  character  of  a  particular  species  of  bacte- 
ria is  established  by  its  examination  under  the  microscope,  artificial 
cultivation,  and  inoculation.  If  an  animal  dies  from  a  l)acterial  disease, 
the  post-mortem  examination  is  conducted  with  the  most  rigorous  asep- 
sis, to  prevent  the  blood  and  organs  of  the  animal  from  becoming  con- 
taminated with  any  other  bacteria.  The  skin  is  washed  in  a  one- 
teiith-per-cent.  solution  of  bichloride  of  mercury,  and  the  instruments 
are  sterilised  by  passing  them  through  the  flame  of  a  spirit  lamp. 
After  the  skin  of  the  animal  has  been  sufficiently  removed,  the  abdomi- 
nal and  thoracic  cavities  are  opened  with  sterilised  instruments  which 
have  not  before  been  used,  so  that  no  bacteria  shall  be  introduced. 
Then  the  organs  are  examined  in  the  following  order:  spleen,  liver, 
kidneys,  heart,  and  lungs.  Small  portions  of  the  blood  and  spleen, 
liver  and  lungs  are  placed  in  nutritive  fluids,  and  after  the  latter  have 
been  poured  upon  culture  plates  in  the  usual  diluted  condition  before 
described,  it  will  be  possible  to  determine  whether  bacteria  are  present, 
and  of  what  species  they  are.  Parasitic  bacteria  which  will  only  grow 
at  body  temperatures  are  cultivated  on  agar  plates  kept  in  a  culture 
oven.  The  colonies  which  develop  upon  the  plates  are  then  examined, 
and  it  is  determined  whether  there  are  one  or  more  species  present,  and 
which  is  the  most  numerous.  Then  follow  the  inoculation  experiments 
of  the  pure  cultures  upon  animals,  such  as  mice,  guinea-pigs,  rabbits, 


g  59.]  MICRO-ORGANISMS.  275 

monkeys,  pigeons,  and  dogs,  for  the  purpose  of  exciting  a  disease  simi- 
lar in  all  respects  to  the  primary  one.  The  inoculation  is  done  by 
simple  subcutaneous  puncture,  by  making  an  incision  and  inserting  the 
culture  beneath  the  skin,  by  placing  it  in  the  anterior  chamber  of  the 
eye,  by  injecting  it  into  the  blood-vessels  or  into  the  peritoneal  or  ab- 
dominal cavities,  by  incorporating  the  culture  in  the  food,  or  introduc- 
ing it  with  the  oesoi)hageal  bougie,  or  by  permitting  it  to  be  inhaled, 
as  Buchner  did,  by  mixing  the  culture  with  sterilised  water  or  bouillon, 
and  then  scattering  this  by  means  of  a  spray  apparatus  as  a  fine  mist 
containing  the  bacteria. 

Intra-uterine  transmission  of  Micro-organisms  from  the  Mother  to  the 
Foetus. — The  possibility  of  the  ti'ansmission  of  micro  orgau isms  from  the 
mother  to  the  foetus  is  of  great  pathological  interest.  That  pathogenic  micro- 
organisms can  pass  from  the  mother  to  the  foetus  has  been  proved  partly 
by  cases  of  anthrax  infection  which  have  occurred  in  man,  and  partly  by 
experiments  upon  animals  (chicken  cholera,  septicaemia  in  rabbits,  malig- 
nant oedema).  Birch-Hirschfeld  has  made  a  careful  microscopic  study  of 
the  placenta  in  pregnant  goats,  rabbits,  white  mice,  and  bitches  suffering 
from  anthrax,  and  he  found  the  bacilli  in  both  the  placenta  and  in  the  foetal 
tissues,  but  in  very  diffei'ent  amounts  in  the  different  animals  experimented 
upon.  He  affirms  that  the  healthy  placenta  will  not  ordinarily  permit  of  the 
direct  passage  into  the  foetal  circulation  of  either  finely  divided  foreign  bodies 
incapable  of  increase  in  numbers,  or  of  micro-organisms;  but  the  placenta, 
without  necessarily  undergoing  any  gross  mechanical  changes  (rupture  of 
the  chorionic  villi  or  of  the  maternal  vessels,  haemorrhages),  may  become 
pervious  from  the  effects  produced  by  the  micro-organisms  circulating 
through  it.  Micro-organisms,  such  as  the  anthrax  bacilli,  can,  when  present 
in  vast  numbers,  penetrate  into  the  foetal  portion  of  the  placenta  if  assisted 
by  alterations  in  the  tissues  forming  the  walls  of  the  blood  sinuses,  and  by 
lesions  in  the  epithelium  of  the  villi.  These  changes  can  be  brought  about 
by  the  injurious  effects  due  to  the  growth  of  the  bacteria.  (See  also  §  83, 
Tuberculosis.) 

Non-pathogenic  Bacteria. — C.  Frankel  gives  the  following  as  the 
principal  non-pathogenic  bacteria  :  1,  Micrococcus  prodigiosus  ;  2,  ba- 
cillus indicus ;  3,  yellow,  white,  orange,  and  red ;  4,  bacillus  megate- 
rium ;  5,  potato  bacillus ;  6,  bacillus  subtilis ;  7,  bacillus  figurans ; 
8,  bacillus  acidi  lactici ;  9,  bacillus  butyricus,  Clostridium  butyricus ; 
10,  bacillus  of  blue  milk ;  11,  bacteria  of  drinking-water  (bacillus 
violaceus,  bacillus  fluorescens) ;  12,  bacillus  phosphorescens ;  13,  bac- 
terium phosphorescens  ;  14,  bacterium  termo  ;  15,  proteus  vulgaris ; 
16,  bacillus  spinosus  ;  17,  spirillum  rubrum  ;  18,  spirillum  centi'icum. 
For  further  description  of  these,  reference  should  be  made  to  the  text- 
books of  Fliigge.  C.  Frankel,  and  others. 

Pathogenic  Bacteria. — The  pathogenic  bacteria  are  the  following  : 
19 


276 


INFLAMMATION   AND   INJURIES. 


1,  Bacillus  antliracis  ;  2,  bacillus  of  malignant  oedema ;  3,  bacillus  of 
pseudo-oedema ;  4,  bacillus  of  tuberculosis ;  5,  bacillus  of  leprosy ; 
6,  bacillus  of  syphilis ;  7,  bacillus  of  glanders  (bacill.  mallei) ;  8,  comma 
bacillus  of  Asiatic  cholera ;  9,  Finkler-Prior's  vibrio ;  10,  Deneke's 
vibrio;  11,  vibrio  Mitschnikoff ;  12,  Emmerich's  bacillus;  13,  bacil- 
lus of  typhoid  ;  14,  spirillum  of  relapsing  fever  (typhus  recurrens) ; 
15,  Plasmodium  malarise ;  16,  Friedliinder's  pneumococcus ;  17,  Fran- 
kel's  piieumonia  bacillus;  18,  bacillus  of  diphtheria;  19,  bacillus  of 
rhinoscleroma  ;  20,  streptococcus  of  erysipelas;  21,  staphylococcus 
pyogenes  aureus ;  22,  and  citrous :  23,  and  albus ;  24,  streptococcus 
pyogenes ;  25,  bacillus  pyocyaneus  ;  26,  gonococcus  ;  27,  bacillus  of  tet- 
anus ;  28,  bacillus  of  chicken  cholera ;  29,  bacterium  of  haemorrhagic 
septicaemia  (rabbit  septicaemia,  swine  fever) ;  30,  bacillus  of  swine 
erysipelas;  31,  bacillus  of  mouse  septicaemia;  32,  micrococcus  tetra- 
genus.  I  shall  refer  again  to  the  bacteria  which  are  of  the  most  im- 
portance from  a  surgical  standpoint  under  the 
chapters  dealing  with  the  infectious  diseases. 

The  Mycetozoa  and  Protozoa.— We  must 
briefly  discuss  the  mycetozoa  aud  i^rolozoa  which 
play  an  important  part  in  the  most  recent  path- 
ological investigations  upon  man  and  animals. 
The  mycetozoa  or  myxomjcetes  ai'e  neither  ani- 
mals nor  plants,  but  a  group  of  living  organisms 
a  midway  between  the  two.  though  nearer  to  the 
amoebae,  the  lowest  form  of  animal  life,  than  to 
the  bacteria,  or  most  elementary  plants.  The 
young  mx'cetozoa  form  slimy  masses  of  proto- 
plasm (Plasmodia),  changing  later  into  vesicles 
with  an  enveloping  membrane  containing  spores, 
and  particularly  zoospores,  which  move  about 
partly  by  means  of  a  waving  flagellum  (Fig.  235, 
cZ,  e)  and  partly  by  the  pulling  out  aud  drawing 
in  of  protoplasmic  processes  (Fig.  235./).  The 
zoospores  nmltiply  for  many  generations  by  di- 
vision of  the  cell  into  two  parts,  and  finally  two 
or  more  of  these  cells  join  and  fuse  together, 
forming  again  a  protoplasmic  body,  or  Plasmo- 
dium, as  it  is  called.  The  mycetozoa,  the  chief 
representatives  of  which  are  myxomycetes  and 
the  small  gi'oup  of  acrasia,  grow  upon  the  decay- 
ing parts  of  plants,  algae,  etc. ;  they  are  typical  saprophytes,  though  some  lead 
n  parasitic  life  in  plants.  The  plasmodiophoi'a  Brassicse  produces  a  destruc- 
tive tumour-like  disea.se  in  the  roots  of  cabbage.  The  mycetozoa  and  micro- 
organisms related  to  them  are  also  pathogenic  for  man  and  animals.  Koch 
surmised  this  long  ago,  but  it  has  only  recently  been  proved. 


Fig.  235. — PI,  young  Plasmodi- 
um from  chondrioderma  dif- 
forme,  containing  two  spores ; 
a,  ungerminated  spores  ( tri- 
chia  vera);  b-d,  exit  of  tlie 
zoospores  from  the  torn  spore 
membrane;  f, ciliated,  /".  non- 
ciliated  amoeboid  zoospores 
(De  Barry). 


s^GO.)  GENERAL   REMARKS  CONCERNING   INJURIES.  277 

The  Protozoa. — The  mycetozoa  come  next  to  the  protozoa,  which  are  usu- 
ally lookt'd  n})()n  as  the  lowest  forms  of  aiiiinal  life,  but  are  not  sharply 
(k'luu'd  from  the  lowest  form's  of  planls.  Tlie  protozoa  consists  i)artly  of  a 
sinyle  cell,  partly  of  several  similar  cells,  with  a  distinct  differentiation  of 
their  protoi)lasms.  They  pass  through  several  stages  of  d(!velopment,  as 
exemplified  by  the  amoebae,  which  are  similar  to  the  white  blood-corpuscles, 
and  which  multiply  by  division,  beginning  with  the  nucleus. 

Leuckart  divides  the  protozoa  into  rhizopods,  sporozoa,  and  infusoria.  The 
rhizopods  consist  of  unenclosed  proto})lasmic  masses  containing  vacuoles  and 
a  nucleus.  They  multiply  by  division,  live  in  solid  nutritive  media,  and  move 
by  putting  forth  finger-like  processes  (pseudopodia).  The  sporozoa  move 
about  like  worms  by  expansion  and  contraction ;  they  multiply  by  means  of 
spores,  and  live  as  parasites;  they  are  nourished  by  fluids  which  pass  by  en- 
dosmosis  through  the  cuticular  envelope  of  the  cell.  This  species  of  patho- 
genic protozoa  is  of  considerable  interest  to  both  man  and  animals.  The 
gregarines,  living  as  parasites  in  insects  and  worms,  belong  to  the  sporozoon 
class,  as  do  also  the  oval  psorosperms,  which  lead  a  parasitic  existence  in 
mammals,  and  the  cylindrical  psorosperms,  found  in  fishes  and  amphibia. 
The  infusoria  belong  to  the  last  division  of  protozoa;  they  do  not  change 
their  shape;  they  possess  cilia  and  an  opening  v.'hich  answers  for  a  mouth, 
and  their  protoplasm  is  made  up  of  a  cortical  and  medullary  portion. 

It  has  been  proved  by  recent  experiments  that  both  the  mycetozoa  and 
protozoa  arc  pathogenic  as  regards  man.  Golgi,  in  Paris  (1886),  showed  that 
peculiar  amoeboid  bodies  were  regularly  present  in  the  blood  during  inter- 
mittent fever  and  malaria,  and  were  almost  always  to  be  found  inside  the 
red  blood-corpuscles,  in  which  they  underwent  lively  amoeboid  movements. 

Numerous  observers  have  established  the  fact  that  this  organism  can  be 
demonstrated  in  the  blood  in  every  case  of  malaria  (the  Plasmodium  mala- 
rias). It  has  hitherto  been  impossible  to  cultivate  the  Plasmodium  malarise 
artificially,  but  Celli  and  Marchiafava  have  produced  malaria  in  healthy 
individuals  by  the  intravenous  injection  of  blood  taken  from  malarial  patients 
and  containing  the  Plasmodium.  This  fact  does  not  necessarily  prove  the 
pathogenic  significance  of  the  plasmodium  malaria,  but  it  has  been  estab- 
lished beyond  a  doubt  by  other  experiments  that  this  organism  is  the  real 
cause  of  the  malarial  fever.  It  has  also  been  proved  that  some  severe  forms 
of  dysenterj'  are  due  to  a  peculiar  amoeba  (Kartalis,  in  Virch.  Archiv,  Bd. 
10.5,  p.  521),  and  molluscum  contagiosum  to  a  species  of  plasmodium.  There 
have  also  been  found  mycetozoa  and  protozoa  within  the  cells  in  various  skin 
diseases,  cutaneous  ulcers,  and  cancers,  but  some  authors  douht  the  truth  of 
this.  1 

§  60.  General  Remarks  concerning  Injuries. — The  injuries  of  the 
human  body  are  divided  into  two  main  groups :  injuries  with  and  in- 
juries without  interniption  of  the  continuity  of  the  external  coverings  of 
the  body,  including  both  skin  and  mucous  membrane.  The  former  class 
we  designate  as  open  bleeding  injuries,  or,  in  short,  as  wounds ;  the 
latter  as  bloodless  or  subcutaneous  injuries.  This  distinction  is  of  the 
greatest  practical  importance,  since  the  prognosis  of  any  injury,  apart 


278  INFLAMMATION   AND   INJURIES. 

from  the  influence  of  the  particular  portion  of  the  body  involved,  is 
chiefly  dependent  upon  whether  the  overlying  skin  or  mucous  mem- 
brane lias  been  divided  or  not.  Every  open  wound,  be  it  ever  so  small 
— for  example  the  prick  of  a  needle — may  be  the  cause  of  an  infectious 
wound  disease,  and  under  these  circumstances  may  prove  fatal  to  the 
patient.  It  must  always  be  borne  in  mind,  as  we  have  learned  in  §  59, 
that  the  micro-organisms  which  are  everywhere  present  outside  the 
body  may,  by  their  admission  to  any  wound,  give  rise  to  the  gravest 
dangers.  This  cannot  occur  in  subcutaneous  injuries  where  the  protect- 
ing skin  and  mucous  membrane  remain  intact  and  ordinarily  prevent 
the  entrance  of  these  noxious  bodies  into  the  system.  The  aim  of  the 
modern  method  of  treating  wounds  is  directed,  as  it  should  be,  towards 
keeping  out  of  the  wound  all  injurious  substances,  including  bacteria, 
and  towards  rendering  them  innocuous  in  case  they  have  gained  en- 
trance. For  this  purpose  we  employ,  in  treating  wounds,  fluids  which, 
like  three-per-cent.  solutions  of  carbolic  acid  and  1  to  1,000  to  1  to 
5,000  solutions  of  bichloride  of  mercury,  are  capable  of  killing  the 
micro-organisms ;  and,  furthermore,  we  only  bring  in  contact  with  the 
wound  such  objects  as  have  been  made  perfectly  sterile.  A  probe  or 
a  finger  wdiich  has  not  been  disinfected  may  cost  the  patient's  life.  In 
the  chapter  on  fractures  we  shall  see  that  in  the  pre-antiseptic  periods 
of  surgery  the  course  of  subcutaneous  fractures  was  entirely  different 
from  that  of  fractures  complicated  by  wounds  of  the  skin.  It  M-as 
in  the  treatment  of  this  latter  class  of  injuries  that  Joseph  Lister,  the 
great  reformer  of  modern  surgery,  began  the  practical  application  of 
his  antiseptic,  or  we  might  say  his  antibacterial,  method  of  treating 
wounds.  Now  we  are  enabled  to  keep  a  fresh  wound  free  from  all 
injurious  substances — in  other  words,  to  prevent  all  infectious  wound 
diseases — and  to  bring  about  a  cure  of  a  great  number  of  injuries 
which  in  the  pre-antiseptic  days  would  undoubtedly  have  proved  fatal. 

According  to  the  causation  of  the  injury,  we  distinguish  between 
injuries  due  to  mechanical  violence  and  those  due  to  thermal  (burning, 
freezing)  or  chemical  influences  (cauterisation).  Subcutaneous  injuries 
are  produced  by  blows  with  blunt  instruments,  or  falls,  while  open 
wounds  are  caused  by  blows  with  more  or  less  sharp  instruments,  and 
take  the  form  of  punctured,  lacerated,  incised,  contused,  or  gunshot 
wounds,  etc.  All  wounds  due  to  blows  with  blunt  instruments  are 
more  or  less  contused  wounds — that  is,  the  borders  of  the  wounds  suffer 
a  more  or  less  extensive  necrosis  as  a  result  of  the  violence  used. 

The  pure  incised,  stab,  and  punctured  wounds  are  simple  wounds, 
while  the  lacerated  and  contused  wounds  are,  as  we  shall  see,  complicat- 
ed wounds.     The  condition  of  the  borders  and  the  depth  of  the  wound 


^Go.]  genf:ral  remarks  concerning  injuries.  27'J 

are  matters  of  great  practical  importance.  If  a  wound  penetrates 
into  a  joint  or  into  one  of  the  large  cavities  of  the  body,  such  as  the 
cranial,  thoracic,  or  peritoneal  cavities,  we  call  it  a  penetrating  wound. 
If  a  portion  of  tissue  is  completely  cut  or  torn  from  its  connections  by 
violence,  a  wound  is  formed  with  loss  of  substance  ;  but  if  the  portion  of 
tissue  still  retains  some  of  its  connections  with  the  surrounding  parts, 
there  results  what  is  called  a  tlap  or  peel  wound.  A  wound  which  is 
clean,  not  poisoned  and  not  infected,  is  distinguished  from  one  which  is 
unclean,  poisoned,  and  infected.  Wu  count  amongst  unclean  wounds  all 
those  in  which  there  is  present  any  foreign  body  whatsoever,  such  as 
dust,  sand,  dirt  of  every  description,  portions  of  clothing,  bullets,  pow- 
der grains,  etc.  "Wounds  affected  with  any  one  of  the  infectious  wound 
diseases  belong  to  the  class  of  infected  wounds  (inflammation,  suppu- 
ration, erysipelas,  wound  diphtheria,  septicsemia,  etc.).  The  wounds  pro- 
duced by  bites  of  snakes,  insects,  etc.,  are  wounds  poisoned  by  animal 
poisons. 

The  symptomatology  and  treatrtient  of  injuries  vary  greatly,  accord- 
ing to  the  portion  of  the  body  involved  and  the  anatomical  peculiari- 
ties of  the  injured  tissues.  Consequently  we  divide  injuries  of  the 
human  body  into  injuries  of  soft  parts,  of  bones,  and  of  joints,  and 
their  symptomatology  and  treatment  will  be  discussed  later  on.  We 
shall  first  give  a  general  outline  of  the  anatomical  changes  occurring  in 
the  healing  of  a  wound. 

Railway  Injuries. — A  very  severe  and  numerous  class  of  injuries  are  in- 
curred from  collisions  between  railway  trains.  Tardieu,  Vibert  and  others 
have  recorded  their  valuable  experiences  on  this  subject,  particularly  Vi- 
bert, who  gave  a  report  of  four  hundred  persons  injured  in  a  railroad  acci- 
dent at  Charenton.  The  occupants  of  the  train  which  moves  the  most  rap- 
idly suffer  the  woi-st  and  most  numerous  injuries.  Upon  those  who  die 
instantly  without  exhibiting  any  external  injury  many  punctiform  hsemor- 
rhages  are  found,  mostly  about  the  head  and  upper  portions  of  the  body, 
similar  to  those  which  occur  in  fracture  of  the  base  of  the  skull.  Bad 
fractures  and  injuries  to  the  soft  parts  are  found  chiefly  in  the  lower  ex- 
tz'emities,  unless  tbe  victims  protect  themselves  in  time  by  rising  from  their 
seats.  Not  infrequently  the  lungs  are  injured  (haemoptysis)  by  contusion  or 
crushing  of  the  thorax,  and  there  may  also  be  injuries  of  the  abdominal  vis- 
cera. Very  often  the  patients  suffer  grave  disturbances  of  the  central  nervous 
system — loss  of  sleep,  headache,  alterations  in  their  mental  condition  of  a 
partly  excitable,  partly  melancholic,  depressed  type,  disturbances  of  digestion. 
loss  of  memory,  easily  excited  intellectual  fatigue,  great  susceptibility  towards 
stimulants  (alcohol,  tobacco),  maniacal  conditions,  auditory  sensations  of  a 
subjective  character,  photophobia,  paralysis  of  accommodation,  disturbances  of 
smell  and  taste,  pargesthesia  of  the  sensory  nerves,  anaesthetic  areas,  particu- 
larly when  there  is  an  organic  lesion  of  the  brain,  muscular  twitchings,  motor 
weakness,  especially  in  the  legs,  paralysis,  disturbances  of  cu'culation  and  res- 


280  INFLAMMATION  AND  INJURIES. 

piration  (increasing  cachexia).  The  patient  exhibits,  in  some  cases,  every  symp- 
tom of  dementia  paralytica.  All  these  nervous  phenomena  are  grouped  to- 
gether under  the  name  of  traumatic  neuroses.  They  are  particularly  liable 
to  make  their  appearance  after  concussion  of  the  brain  and  spinal  cord,  and 
sometimes  are  caused  by  relatively  slight  accidents.  In  the  majority  of  cases 
it  is  a  psychosis  and  neurosis,  similar  to  hysteria,  without  actual  changes  in 
the  central  nervous  system  (Charcot,  Striimpell).  Albin  Hoffmann  has  cor- 
rectly pointed  out  that  a  traumatic  neurosis  is  of  much  less  frequent  occur- 
rence in  individuals  previously  perfectly  healthy  than  has  hitherto  been  sup- 
posed ;  the  number  of  malingerers  is  large,  and  is  steadily  increasing  since 
the  accident  law  went  into  effect.  In  the  minority  of  the  cases  thei*e  do  occur 
progressive  pathological  changes  in  the  central  nervous  system  as  a  direct 
result  of  the  accident.  The  prognosis  of  these  cases  is  very  unfavourable  ; 
they  often  lead  to  chronic  disease  of  the  cortex  of  the  brain ;  less  frequently  it 
is  located  in  the  spinal  cord.  The  English  physicians  have  given  the  name 
of  railway  spine  to  the  secondary  diseases  of  the  central  nervous  system  fol- 
lowing railway  accidents. 

§  61.  The  Anatomical  Phenomena  in  the  Healing  of  a  Wound. — The 

anatomical  jphenomena  manifested  'in  the  healing  of  wounds  were  lirst 
studied  exhaustively  by  Thiersch,  and  all  the  recent  investigations  have 
been  based  upon  the  correct  statements  which  he  made.  We  ordinarily 
distinguish  two  kinds  of  repair  in  a  wound  :  (1)  the  direct  primary 
agglutination  of  the  divided  parts,  called  healing  per  pynmam  inten- 
tionem  /  and  (2)  the  repair  of  a  wound  by  the  formation  of  granulation 
tissue,  or,  in  other  words,  repair  accompanied  by  suppuration,  called 
healing  jy(?/'  secundain  intentlonem. 

Healing  per  Primam  Intentionem. — Healing  by  primary  intention 
takes  place  in  all  fresh  aseptic  wounds,  particularly  in  those  produced 
in  the  course  of  an  operation,  the  borders  of  the  latter  class  (operation 
wounds)  being  held  by  the  stitches  in  continual  contact  until  they  ad- 
here together.  Those  wounds  which  are  treated  aseptically  heal  more 
rapidly  than  those  treated  antiseptically — that  is,  than  the  wounds  irri- 
tated by  antiseptic  solutions  (bichloride,  carbolic  acid,  etc.). 

Macroscopic  Phenomena  in  Healing  by  Primary  Intention. — The  macro- 
scopic phenomena  manifested  in  the  healing  of  wounds  j9(?/'  primairh 
intentionem  are  briefly  as  follows :  "We  ordinarily  find,  in  the  first 
place,  that  the  borders  of  the  wound  become  agglutinated  by  a  coagu- 
lum  made  up  of  blood  and  lymph.  During  the  next  four,  six,  or  eight 
days  the  union  of  the  wound  is  definitely  established,  the  coagulum 
in  and  around  the  wound  space  becoming  replaced  by  new  cells  and 
blood-vessels,  the  former  of  which  gradually  change  into  the  fibrillar 
connective  tissue  making  up  the  cicatrix.  In  the  case  of  small 
wounds,  or  slight  losses  of  substance,  there  is  usually  developed  as  a 
result  of  the  coagulation   of   the   blood   and  lymph  a  crust,  beneath 


§61.]   ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.   281 

wliich  the  conii)lotc  healing  of  the  wound  is  accomplished  (called 
healing  under  a  scab  (see  page  177).  The  skinning  over  of  the  wound 
proceerls  from  its  borders  by  proliferation  of  the  cells  of  the  rete 
Mali)ighii  and  of  the  sebaceous  glands,  if  the  latter  still  exist  in  the 
surface  of  the  wound.  The  young  cicatrix  at  first  forms  a  fine  red 
line,  which  subsequently  becomes  gradually  whiter  and  softer.  The 
cicatrices  of  many  wounds  which  unite  by  primary  intention  disajv 
pear  in  course  of  time  more  or  less  completely. 

Healing  by  Secondary  Intention. — The  healing  per  seeun  flam  inten- 
tionem,  with  the  formation  of  granulation  tissue  and  pus,  takes  place 
in  badly  contused  wounds,  or  where  there  has  been  a  loss  of  substance 
and  it  has  been  impossible  to  obtain  direct  adhesion  of  the  divided  tis- 
sues with  the  aid  of  stitches,  and  also  in  wounds  which  have  been  neg- 
lected and  not  treated  aseptically,  and  in  wounds  which  have  been 
infected  by  micro-organisms. 

Macroscopic  Phenomena  in  the  Healing  of  Wounds  by  Secondary  In- 
tention.— Macroscopically,  the  phenomena  which  take  place  in  this 
form  of  healing  of  a  wound,  involving,  for  example,  vascular  soft  parts, 
are  somewhat  as  follows :  Until  the  expiration  of  about  twenty-four 
hours  after  the  reception  of  the  injury  the  various  tissues  exposed  in 
the  surface  of  the  wound  are  clearly  distinguishable  from  one  another. 
Later  on  the  outlines  of  the  various  tissues  in  the  wound  are  obscured 
by  a  jelly-like  covering  consisting  of  a  reddish-yellow  fluid,  a  mixture 
of  blood  serum  and  lymph  which  has  been  poured  out  from  the  wound. 
After  about  two  to  three  days  the  greyish-red  gelatinous  wound  surface 
begins  to  take  on  a  granular,  red  appearance,  and  the  wound  begins  to 
granulate,  or  to  form  vascular  cellular  germinal  tissue  called  granula- 
tion tissue,  from  which  there  is  ordinarily  produced  an  exudate  con- 
taining a  great  (piantity  of  round  cells — in  otlier  words,  pus.  If  the 
wound  heals  aseptically  as  a  result  of  most  careful  disinfection  and 
most  rigorous  aseptic  treatment,  the  secretion  will  be  slight,  and  fre- 
quently actual  pus  formation  will  not  take  place.  Profuse  suppura- 
tion will  only  occur  in  a  wound  which  is  not  aseptic. 

In  contused  wounds  with  destruction,  or  rather  necrosis,  of  the  tis- 
sues, the  dead  portion  of  the  tissues  is  first  cast  off  by  the  process  of 
granulation  ;  the  wound  "  purifies  itself."  Under  these  conditions  it  is 
possible  to  obtain  with  aseptic  dressings  a  more  rapid  healing,  unac- 
companied l)y  profuse  secretion,  suppuration,  or  decomposition. 

The  Skinning  Over  of  a  Granulating  Wound. — The  covering  over  of 
a  granulating  surface  with  skin  proceeds  gradually  from  the  margins  of 
the  wound,  and  is  accompanied  by  a  simultaneous  shrinkage  of  the 
granulation  tissue.     If  the  cutis  has  not  been  entirely  destroyed,  if 


282 


INFLAMMATION  AND  INJURIES. 


there  are  still  traces  of  the  Malpighian  stratum  present,  or  if  the  epi- 
thelium of  the  sebaceous  glands  is  intact,  the  remains  of  these  struc- 
tures will  form  the  starting  points  within  the  granulating  area  from 
which  skin  will  spread  outwards  over  the  granulating  surface.  All 
cicatrices  which  are  accompanied  during  their  formation  by  suppura- 
tion are  thicker,  more  extensive  and  unsightly  than  the  small  linear 
cicatrices  resulting  from  primary  union. 

Histological  Phenomena  in  the  Healing  ofWounds. — The  mhmte  phe- 
nomena which  take  place  in  the  repair  of  a  wound  involving  vascular 


Fio.  236. — Wound  in  the  liver  (cuneiform 
excision),  twontv-lbur  houi-s  old.  a. 
Border  of  the  liver;  S,  coagulum  of 
blood  in  the  defect.  Commencing  col- 
lection of  wandering  cells  in  the  bor- 
ders of  the  wound. 


Fig  237  — Immiirr'ited  white  blood-corpuscles 
in  a  foui  coiiiLitd  defect  in  the  middlt  of 
a  dead,  hardened  piece  of  liver  substance, 
which  had  been  implanted  with  antiseptic 
precautions  in  the  abdominal  cavity  of  a 
rabbit  twenty-four  hours. 


tissue  is  practically  the  same  whether  the  wound  heals  with  the  forma- 
tion of  pus  or  without  it.  Healing  by  primary  intention  is  character- 
ised by  the  formation  of  a  minimum  amount  of  germinal  tissue  unit- 
ing the  borders  of  the  wound,  while  in  healing  by  secondary  intention 
the  amount  of  germinal  tissue  is  much  more  considerable.  After  every 
wound,  no  matter  how  free  the  healing  may  be  from  reaction,  there 
follows  an  inflammation  in  the  sense  described  in  §  56,  and  as  a  result 
of  this  there  is  a  cellular  infiltration  of  the  borders  of  the  wound  with 
wandering  cells  (Fig.  236).  This  cellular  infiltration  of  the  borders  of 
the  wound  steadily  progresses,  advancing  by  degrees  into  the  wound,  and 
taking  the  place  of  the  blood  coagulum  which  is  present  (Fig.  237).  In 
cases  of  pronounced  inflammatory  infiltration  of  the  borders  of  the 


g61.]   ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.   283 


V-.". 


.:?c:. 


^^^: 


wound  the  old  tissues  in  the  immediate  neighbourhood  are  more  or  less 
completely  destroyed  by  fatty  degeneration.  On  about  the  third  day  the 
wound,  or  the  wound  cleft,  will  be  found  tilled  with  a  tissue  consisting 
almost  exclusively  of  round  cells,  with  a  very  small  amount  of  inter- 
mediate substance, 
while  here  and 
there  are  scattered 
the  remains  of  the 
blood  coagulum. 
Later  on  there  will 
be  found  lai'ge 
epithelioid  cells 
(Figs.  238,  239), 
the  actual  forma- 
tive cells  of  the 
granulation  tis- 
sue or  cicatrix — 
fibroblasts  as  they 
are  called — which 
change  into  the 
fibrils  of  the  fibril- 
lar connective  tis- 
sue (Fig.  239,  a). 
I  used  to  believe  that  these  formative  cells  were  direct  descendants  of 
the  emigrated  w^hite  blood-corpuscles,  but  recent  discoveries  have  forced 
me  to  abandon  this  view  as  incorrect,  and  I  have  come  to  the  conclu- 
sion that  Thiersch,  Recklinghausen  and  others  are  right  in  stating  that 
the  original  fixed  connective-tissue  cells  and  the  entlothelium  of  the 
vessels  are  the  essential  factors  in  the  formation  of  the  cicatrix.  Zieg- 
ler  has  also  recently  adopted  this  view.  The  numerous  nuclei  in  differ- 
ent stages  of  division  which  can  be  demonstrated  in  the  fixed  connec- 
tive-tissue cells  and  the  endothelium  of  the  vessels  as  the  latter  undergo 
rapid  proliferation  are  proofs  of  the  correctness  of  this  theory.  The 
newly  formed  tissue  cells  can  also  become  wandering  cells.  The  regen- 
erative processes  within  the  injured  organs  are  likewise  carried  on  by 
the  fixed  tissue  cells.  The  connective-tissue  cell  always  gives  rise  to  a 
new  connective-tissue  cell,  an  epithelial  cell  to  an  epithelial  cell,  but  a 
connective-tissue  cell  is  never  formed  from  an  epithelial  cell,  or  vice 
versa.  The  leucocytes  present  either  perish — i.  e.,  are  either  absorbed 
by  the  growing  tissue  cells,  particularly  the  polynuclear  leucocytes — or 
they  wander  back  into  the  circulation  as  in  inflammation.  On  the  other 
hand,  I  believe  that  some  of  the  protoplasm  of  the  wandering  cells  is 


Fig.  238. — W^ound  in  the  kiduey  on  the  fourth  day.  Larffe  forma- 
tive cells,  varying  iu  shape  {h).  a,  E.xtravasation  of  blood,  with 
here  and  there  masses  of  iirotoplasmie  formative  material  (f) 
produced  by  a  fusion  of  the  white  blood-corpuscles. 


284 


INFLAMMATION  AND  INJURIES. 


employed  as  cell  material  in  both  the  scar  formation  and  the  regenera 
tive  processes  carried  on  in  the  original  fixed  tissue  cells  of  the  neigh- 
bourhood. I  am  unable  to  say  whether  the  white  blood-corpuscles  can 
themselves  form  fibrillar  connective  tissue  when  the  circulation  is  sufti- 

ciently  active,  for  example,  in  a 
V       '^  granulating   wound    of    granula- 

^        '  i  tions,  but  their  importance  in  this 

respect  is  much  less  than  that  of 
the  fixed  tissue  cells — i.  e.,  the 
cells  of  the  connective  tissue  and 
the  endothelium  of  the  vessels 
which  have  been  demonstrated  to 
be  the  real  producers  of  the  scar 
and  are  called  fibroblasts.  Reinke 
and  others  believe  that  further 
development  is  possible  in  those 
wandering  cells  which  make  their 
appearance  after  the  proliferation 
of  the  fixed  cells  has  begun,  and 
which  exhibit  great  vital  energy. 
Ribbert  considers  it  probable  that 
the  lymphogenic  leucocytes  with 
a  single  nucleus  are  capable  of 
taking  part  in  the  construction  of 
new  connective  tissue  by  helping 
to  cover  over  the  lymph  cavities 
and  spaces  with  endothelium.  / 

New  Formation  of  Tissue  accord- 
ing to  Ziegler,  Marchand,  Tillmanns. 

— Ziegler  was  the  first  to  make  an 
exhaustive  study  of  the  manner  in 
which  new  tissue — the  fibrillary  con- 
nective tissue— is  formed.  He  fitted  together  two  pieces  of  glass,  about  ten 
to  twenty  rnillimeti-es  long  and  ten  millimetres  broad,  and  made  them  ad- 
herent to  each  other  at  the  corners  with  porcelain  cement,  leaving  an  emp- 
ty space,  accessible  by  capillarity  from  the  sides,  into  which  the  white  blood- 
corpuscles  and  the  lymphatic  fluid  could  penetrate  after  the  glass  plates 
had  been  placed  beneath  the  skin  or  periosteum  or  inside  one  of  the  cavi- 
ties of  the  body  of  an  animal.  The  plates  were  left  in  place  inside  the 
animal  from  ten  to  twenty-five  to  fifty  days,  and  when  removed  were  gent- 
ly washed,  and  then  placed  for  two  days  in  a  O'l  per-cent.  solution  of  hy- 
perosmic  acid,  after  this  in  spirits  of  glycerine,  and  finally  in  pure  glyc- 
erine. My  own  method  consists  in  hardening  in  absolute  alcohol  pieces 
of  lung,  liver,  and  kidney,  measuring  about  one  cubic  centimetre,  and  mak- 


FiG.  239. — Fifth  day;  a  piece  of  hardened  liver 
with  a  defect  in  the  middle;  large  formative 
cells  which  have  developed  from  fixed  tissue 
cells ;  a,  clearly  defined  fibrillary  connective 
■  tissue  formed  from  cells ;  S,  masses  of  proto- 
plasmic formative  material  with  commencing 
aift'erentiation  seen  by  the  appearance  of 
larger  nuclei ;  c,  solid  sprouts  from  the  ves- 
sels ;  d,  blood-vessel. 


^61.]   ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.  285 

iiig  holes  and  notches  in  them,  and  then  placing'  them  with  eveiy  anti- 
septic precaution  in  the  peritoneal  cavity  of  a  rabbit.  Sections  are  after- 
wards cut  from  these  specimens,  and  when  examined  under  the  microscope 
will  give  a  very  beautiful  picture  of  the  new  formation  of  tissues.  Ziegler 
came  to  the  conclusion  that  the  emigrated  white  blood-cor])uscles  undergo 
further  development,  and  form  fibrillar  connective  tissue  if  there  is  a  suffi- 
cient circulation  of  lymphatic  fluid,  and  especially  if  enough  nutrition  is 
su])plied  by  the  development  of  new  vessels.  Ziegler  has  also,  like  mj^self, 
modi  tied  this  view.  We  now  know  that  in  Ziegler's  glass  plates,  and  in  my 
pieces  of  dead  tissue,  the  new  tissue  is  chiefly  developed  from  the  cells  of  the 
newly  formed  vessels.  Salzer  has  also  made  recent  investigations  upon  the 
healing  up  in  a  wound  of  foi'eign  bodies,  and  Marchand  particularly  has  made 
some  very  valuable  experiments  both  in  the  healing  in  of  foreign  bodies  and 
in  the  new  formation  of  tissue.  Marchand  employed  chiefly  bits  of  sjjonge, 
cork,  elder-wood  pith,  and  pieces  of  lung  and  liver  injected  with  blue  gela- 
tine, which  he  buried  in  the  peritoneal  cavities  of  guinea-pigs  and  rabbits. 
After  four  to  seven  hours  a  development  of  a  network  of  fibrin  and  an  emi- 
gration of  numerous  leucocytes  took  place.  After  twenty-four  to  thirty 
hours,  and  latei-,  the  foreign  body  became  intimately  connected  with  the  peri- 
tonaeum, and  within  it  were  found  new  cell-forms  derived  from  the  fixed  ele- 
ments in  the  neighbourhood,  these  cells  being  mostly  spindle-shaped,  with 
large,  elongated  nuclei,  though  round  cells  are  also  present.  All  these  cells 
spring  from  the  endothelium  of  the  peritonaeum,  the  fixed  connective-tissue 
cells,  and  the  cells  of  the  walls  of  the  vessels,  etc.,  in  which  the  nuclei  are 
seen  forming  variously  shaped  figures  in  the  pi'ocess  of  their  segmentation. 
There  are  also  present  giant  cells,  often  having  an  extraordinary  number  of 
nuclei.  The  giant  cells  are  formed  by  the  fusing  together  of  fixed  tissue 
cells,  and  possess  the  power  of  absorbing  leucocytes  ;  but  they  exhibit  no 
progressive  development,  and  later  on  perish  by  fatty  degeneration.  Giant 
cells  are  only  found  in  those  foreign  bodies  (bits  of  sponge,  elder  pith)  whose 
absorption  presents  difficulties;  and  Marchand  did  not  discover  them  in  the 
pieces  of  lung,  as  the  tissue  of  which  it  consists  is  i-eadily  destroyed,  and  can 
be  absorbed  by  the  leucocytes.  The  granulation  cells  are  likewise  the  off- 
spring of  the  fixed  tissue  cells,  and  not  of  the  single  or  polynucleated  leuco- 
cytes. Moreover,  the  offspring  of  the  fixed  tis5:ue  cells  very  often  become 
wandering  cells.  Marchand  saw  segmentation  figures  in  the  nuclei  of  the 
mononuclear  leucocytes.  The  polynucleated  leucocj'tes  develop  from  those 
with  a  single  nucleus,  and  are  retrogressive  in  nature.  The  leucocytes  take 
no  part  in  the  formation  of  new  tissues,  but  they  do  take  part  in  the  forma- 
tion of  fibrin  which,  according  to  Marchand,  is  produced  by  substances  liber- 
ated by  the  death  of  the  white  blood-corpuscles.     (See  also  page  250.) 

Sherrington  and  Ballance  maintain  that  the  cicatrix  is  formed  from  the 
cells  of  the  plasma,  these  cells  being  supplied  with  nourishment  by  the  proto- 
plasm of  the  white  blood-corpuscles. 

The  Formation  of  Fibrillar  Connective  Tissue. — Ziegler's  and  mj  own 
experiments  show  that  the  librillar  connective  tissue — or,  in  other 
words,  the  cicatrix — is  formed  from  the  fibroblasts  in  tlie  following 
way  :  The  formative  cells  are  at  first  round,  and  then  enlarge,  and  look 


286 


INFLAMMATION   AND   INJURIES. 


like  large,  round  epithelium  ;  or  they  are  more  elongated,  or  possess  one 
or  more  processes,  some  becoming  spindle-shaped,  others  club-shaped ; 
or  they  may  form  branching  cells  or  polyuuclear  giant  cells.      The 

processes  repeated- 

__..^.^.Ajr.     ;    .,  ■  ly  anastomose  with 

■■■'-''  ..  ;^  '  A  ■  one  another.     The 

:       ,,      > /■  '  '      number  of  the  large 

'    \'h      '}  ,    ^       J    ^    :    :  t'    il      formative  cells  then 

■      '     : ::    --■■■  '■  '    :  rapidly      increases, 

;^"  ■  ■  ■•:■  i      ar         \     ."  .  ' 

.:      '^   i  ••?  '  ;     a  i  '■-.    \>     and    in    certain    lo- 

^^  i^     .,         ?     •  V     i    :    \-     ':  ■!)     cahties      they      lie 

':'"'.     i^--  ^.     ■    '■  '  .       '^^   ^     i'/      close  together.   The 

h  ,■-•.-;:    .:i5    ?  '^^i;:  ^   ..;      .  .  if  ^\  ;■   i  i  is.'       fibrillar     tissue     is 

Fio.  240. — Wound  in  the  liver  in  the  staofe  of  cicatrisation,  tenth  formed    in    pPJ't    di- 
day.    a,  Younir  cicatricial  tist^ue;  i,  liver  tissue  which  has  par-  -1 

tially  undergone  fatty  degeneration  in  the  neighbourhood  of  recti V  froill  the  pro- 
the  cicatrix,  and  contains  many  red  and  white  blood-corpuscles.  "  c  i 

toplasm      01      the 
formative  cells,  and  is  consequently  intracellular  in  its  origin,  or  it  comes 
from  a  homogeneous  intercellular  ground  substance  or  stroma  which 
has  previously  developed  from  the  formative  cells.     In  the  intracellu- 
lar  fibre-formation 


fibres  make  their 
appearance  on  one 
or  both  sides  of  a 
cell,  or  at  one  ex- 
tremity of  it,  or  in 
a  process,  and  unite 
with  the  fibres  of 
the  adjoining  cells. 
The  nucleus,  to- 
gether with  a  por- 
tion of  the  proto- 
]ilasm  of  the  form- 
ative cell,  persists 
as  a  fixed  connect- 
ive -  tissue  cell 
(Figs.  239,  a,  240). 
The  direction  taken 
by  the  fibres  is 
usually  the  same  over  a  considerable  area,  the  formative  cells  playing 
no  part  in  determining  the  direction  of  the  fibres.  As  illustrated  in 
Fig.  240,  the  cicatrix  is  in  the  beginning  rich  in  large  elongated  cells, 
the  remains  of  the  earlier  formative  cells,  which  in  part  become  changed 


Fig.  241. — Fourteenth  day  ;  cicatrised  defect  («)  in  a  piece  of  dead, 
hardened  lung  (4);  the  latter  is  tilled  with  numerous  wander- 
ing and  formative  cells,  especially  in  the  neighbourhood  of  the 
defect,  or  rather  the  cicatrix. 


^61.]   ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.  287 


into  fibres.  The  size  of  these  celhilar  remains  subsequently  diminishes, 
the  fibrous  tissue  becomes  thicker,  and  the  cicatrix  is  complete  (Figs. 
241.  •24-2.  24:"5V 

New  Formation  of  Vessels. — The  formation  of  new  vessels  proceeds 
hand  in  hand  with  the  abuve-described  tissue  formation.     In  fact  it  is 


\\\^J^m'^\^lf:iflg 


Wi 


:j^ 


Fio.  242. — Seventeenth  day;  cicatrised  de- 
fect («)  iu  a  piece  of  a  dead,  hardened 
liver  (*). 


Fig.  243. — Twenty-eiorhth  day ;  healed  wound 
in  the  liver,  cicatrix  (a)  containing  blood 
pigment. 


this  that  renders  possible  the  further  development  of  the  accumulated 
formative  cells ;  and  the  cells  of  the  newly  formed  vessels  also  contribute 
very  essentially  to  the  formation  of  the  new  tissue  which  makes  up  the 
cicatrix. 

In  the  earliest  stages  in  the  repair  of  a  wound,  the  formative  cells, 
or  the  cells  of  the  granulation  tissue,  receive  their  nutriment  from  the 
stream  of  plasma  escaping  from  the  vessels  in  the  neighbourhood. 
As  Thiersch  has  shown,  this  intercellular  circulatory  system  can  be 
injected  through  the  blood-vessels.  But  this  arrangement  for  supply- 
ing nutrition  to  the  cells  is  only  temporary,  and  the  formation  of 
new  blood-vessels  is  required  for  the  further  process  of  repair  in  a 
wound. 

The  development  of  new  blood-vessels  is  the  result  of  an  actual 
sprouting  from  the  walls  of  pre-existing  vessels  (Figs.  239,  244,  245). 
There  is  first  noticed  on  the  external  surface  of  a  capillary  loop  a  gran- 
ular accumulation  of  protoplasm,  which  graduall}-  enlarges  (Fig.  244, 
a,  h.  c)  and  grows  into  a  solid  protoplasmic  filament,  which  contains  a 
nucleus.  This  protoplasmic  filament,  simple  (Fig.  244. /")  or  branched 
(Fig.  244,  d,  e,  g)^  joins  either  with  the  wall  of  another  vessel,  or  unites 
with  another  similar  sprout  advancing  in  the  opposite  direction  and 
springing  from  another  similar  capillary  loop  (Fig.  244,  d.f,  g).  There 
are  also  formed,  not  infrequently,  protoplasmic  filaments  which  turn 


288 


INFLAMMATION   AND  INJURIES. 


back  in  an  arch  to  the  same  vessels  from  whicli  they  started.  Further- 
more, processes  from  the  spindle-  or  club-shaped  or  branching  forma- 
tive cells  of  the  intercapillarj  tissue  join  with  the  sprouts  from  the 
walls  of  the  vessels,  and  thus  the  material  in  the  formative  cells  helps  in 
the  formation  of  the  new  blood-vessels.    After  a  certain  length  of  time 

the  originally  solid 
protoplasmic  fila- 
ments become  hol- 
low from  liquefac- 
tion of  their  in- 
terior, giving  rise 
to  an  open  com- 
munication with 
the  mother  vessels, 


Fig.  244. — Development  of  blood-vessels  by  buddina:;  dittorent  forms  of  Inals.  a,  A,  c,  First 
stages;  (/,_/',  </,  simple  and  brandling  solid  buds;  «,  vascular  bud  which  is  being  made  hol- 
low and  whicli  already  contains  blood-corpuscles. 

while  the  daughter  vessels  become  more  and  more  hollowed  out  and 
gradually  filled  with  blood  from  the  mother  vessels.  Not  infrequently 
an  open  pouch  (Fig.  2-44,  b)  develops  at  the  very  outset  from  the  wall 
of  the  vessel,  gradually  tapering  off  into  a  filament  of  protoplasm. 
The  walls  of  the  daughter  vessel,  the  newly  developed  capillary,  are  at 
first  homogeneous,  later  on  nuclei  are  added,  and  they  take  on  a  plain- 
ly recognisable  cellular  structure,  consisting  of  flat  cells  (endothelial 
cells).  Subsequently  the  walls  of  the  vessel  are  strengthened  materi- 
ally by  the  formative  cells  in  the  neighbourhood. 

The  above-mentioned  protoplasmic  filaments  shooting  out  from  the 
walls  of  the  vessels  are  made  up  partly  of  the  cells  of  the  vessel  walls, 
and  partly,  as  I  believe  I  have  observed,  of  white  blood-corpuscles 
which  have  passed  through  the  capillary  wall.  At  a  later  period  a 
shrinkage  takes  place  in  the  newly  formed  connective  tissue  of  the 


§61.]    ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.  289 


cicatrix,  and  a  portion  of  the  vessels  disappear,  causing  tlie  original  red 
scar  to  become  pale. 

The  manner  in  which  the  wound,  or  rather  the  granulating  surface, 
is  covered  with  skin,  has  been  brietlj  stated  above.  For  the  purpose 
of   healing    up    large 

granulating    surfaces,  j 

l\everdin  employed 
the  transplantation  of 
small  particles  of  skin. 
This  method  of  skin 
transplantation  was, 
however,  iirst  made  a 
useful  procedure  by 
Thiersch  (see  §  42). 
The  adhesion,  or 
rather  the  union,  of  a 
piece  of  skin  on  to  its 
new  bed  takes  place, 
according  to  Thiersch, 
bj  the  vessels  in  the 
granulations  and  in 
the  bit  of  skin  be- 
coming connected 
through  the  intercel- 
lular passages  ;  these  passages  conduct  the  blood  circulating  in  the  gran- 
ulation vessels  directly  into  and  back  from  the  vessels  in  the  pieces  of 
skin.  There  is  subsequently  a  formation  of  permanent  vessels  which 
supplants  this  provisional  circulation.  My  ow^n  experiments,  and  those 
of  Ziegler,  show  that  there  is  at  the  outset  a  rapid  emigration  of  white 
blood-cells  accompanying  the  union  or  adhesion  of  the  transplanted  bit 
of  skin.  But  the  leucocytes  are  of  no  importance  in  the  final  taking 
root  of  the  transplanted  skin,  the  actual  accomplishment  of  which  is 
brought  about  by  the  fixed  tissue  cells,  the  newly  formed  vessels,  and 
their  cells.  The  minute  phenomena  which  take  place  during  the  taking 
root  of  a  Thiersch  skin  graft  are  practically  the  same  as  in  any  union 
by  primary  intention.  The  surface  of  the  wound  and  the  adhering 
layer  of  skin  are  filled  with  round  cells.  This  round-celled  infiltrate  is 
then  gradually  changed  into  granulation  tissue,  accompanied  by  the 
sprouting  of  the  vessels  on  the  surface  of  the  wound,  and  finally  the 
granulation  tissue  becomes  fibrillar  connective  tissue.  The  transplanted 
skin  flap  is  at  the  outset  passive,  but  from  the  third  day  on  it  becomes 
vascularised  by  sprouts  from  the  vessels  on  the  surface  of  the  wound. 


Fm.   245.— Development    of   new   blood-vessels    by    budding. 
Seventeenth  day.     Wound  in  the  liver. 


290  INFLAMMATION   AND   INJURIES. 

In  spite  of  this  two  days'  interruption  in  the  circulation  of  the  blood, 
the  majority  of  the  tissue  elements  in  the  cutaneous  ^raft  retain  their 
function  and  vitality,  and  only  the  epidermal  layer,  with  a  portion  of 
the  rete  Malpighii,  and  the  greater  part  of  the  vessels,  will  be  found 
to  perish,  the  latter  by  atrophy  and  hyaline  degeneration.  From  the 
third  or  fourth  day  on  the  graft  takes  an  active  part  in  the  process  of 
healing  into  its  new  bed,  as  the  epithelial  cells  (in  the  transversely  cut 
hair  follicles  and  excretory  ducts)  which  lie  ui)on  the  exudate  prolif- 
erate and  make  their  way  into  the  bed.  Garre  says  that  fourteen  days 
after  the  transplantation  all  the  granulation  tissue  has  become  replaced 
by  connective  tissue,  and  the  healing  is  complete. 

Reunion  of  Entirely  Severed  Portions  of  the  Body. — Parts  which  have 
been  completely  severed  from  all  their  connections  with  tlie  body  may 
again  become  united  in  the  same  manner  as  the  skin  grafts  of  Rever- 
din  and  Thiersch.  But  this  is  only  possible  in  the  case  of  small  por- 
tions of  tissue,  such  as  the  tip  of  the  nose  or  of  the  fingers.  To  these 
phenomena  belong  the  reposition  of  teeth  which  have  been  extracted, 
the  transplantation  of  living  or  dead  bone  or  cartilage  into  defects  in 
bone,  etc.  The  success  of  all  these  operations  is  dependent  upon  the 
strictest  observance  of  the  rules  of  asepsis.  The  transplantation  of  the 
various  tissues  above  mentioned  has  been  described  on  page  143. 

The  Formation  of  a  Cicatrix  in  a  Vessel,  or  the  Organisation  of  a 
Thrombus. — The  formation  of  a  cicatrix  in  a  vessel  which  has  l)een 
wounded  or  ligated,  or,  in  other  words,  the  onjanisation  of  a  throtn- 
hus,  is  of  special  importance. 

The  following  is  a  brief  description  of  the  manner  in  which  the  thrombus 
forms  in  a  vessel  :  Since  Briicke  made  his  famous  experiments,  we  know 
that  the  blood  is  kept  fluid  within  the  walls  of  the  vessels  because  of  its  contact 
with  a  normal  endothelium,  and  because  of'its  constant  movement.  If  either 
one  of  these  two  conditions  is  lacking,  if  the  integrity  of  the  endothelium  of 
the  vessels  is  altei^ed  in  any  way  by  an  inflammation  or  traumatism,  if  the 
blood  escapes  from  the  walls  of  the  vessels,  or  if  its  circulation  is  interrupted 
— for  example,  by  ligation  of  the  vessel— the  blood  will  then  coagulate;  it  will 
form  a  thrombus. 

The  thrombus  which  develops  after  ligation  of  an  artery,  for  example, 
extends  fi'om  the  point  at  which  the  ligature  has  been  applied  to  the  nearest 
lateral  branch  above  and  below.  The  same  holds  true  as  regards  the  veins. 
We  know,  however,  that  in  a  vein  extensive  thrombi  form  much  more  readily 
than  in  an  artery,  and  this  is  the  case  not  only  when  the  lumen  is  occluded 
by  a  ligature  or  an  injury,  but  also  when  there  occurs  a  pronounced  stasis 
and  obstruction  to  the  forward  movement  of  the  blood.  If  two  ligatures  are 
applied  to  a  vessel  with  a  moderate  interval  between  them,  the  blood  will 
coagulate  between  these  ligatures;  but  a  thrombus  does  not  always  develop 
after  the  ligation  of   a  vessel.     Baumgarten   demonstrated  that  the  blood 


§61.]   ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.  291 

lying  between  two  li<?atui'es  may  remain  fluid  for  three,  four,  or  even  twelve 
to  fifteen  days  if  the  lij^alion  is  carefully  performed,  and  ])articularly  if  the 
wall  of  the  vessel  is  not  isohited  from  its  connections  with  the  adjoining 
tissues,  ana  if  its  nutrition  from  the  vasa  vasorum  is  not  interfered  with. 
Under  such  conditions  the  endothelium  appears  to  remain  intact  and  per- 
forms its  functions  normally,  and  consequently  the  blood,  though  not  mov- 
ing, retiiins  its  fluid  character. 

In  wounds  or  injuries  involving  only  a  portion  of  the  circumference  of  a 
vessel  there  is  not  always  the  formation  of  a  thrombus  filling  the  entire 
lumen  of  the  vessel.  The  rent  in  the  wall  is  often  completely  filled  by  a 
thrombus  which  organises,  leaving  only  a  thickening  of  the  vessel  at  the  site 
of  the  injury.  This  method  of  repair  may  take  place  in  vessels  of  any  size 
whatsoever.  Again,  a  thrombus  which  at  the  outset  only  partially  fills  the 
lumen  may  finally  cause  its  total  occlusion  by  the  addition  to  it  of  one  layer 
of  coagulum  after  another. 

We  have  to  deal  mainly  with  thrombi  occurring  after  an  injury  or  the 
ligation  of  a  vessel.  Mention  should  also  be  made  of  the  so-called  compres- 
sion thrombi,  which  form  when  the  blood  is  brought  to  a  standstill  as  a  re- 
sult of  compression  from  without,  as  by  tumours;  of  the  dilatation  thrombi  in 
aneurysms  and  varices ;  of  the  thrombi  caused  by  inflammatory  processes  in 
the  walls  of  the  vessels  accompanied  by  destruction  of  the  endothelium,  etc. 

But  changes  in  the  walls  of  the  vessels  and  primary  distui-bances  in  the 
circulation  are  not  always  sufficient  in  themselves  to  produce  coagulation  of 
the  blood;  the  cause  for  the  thrombosis  must  be  sought  for  not  infrequently 
in  a  general  alteration  in  the  composition  of  the  blood.  Silberman  has  seen 
multiple  coagula  form  during  life  from  acute  poisoning  by  the  salts  of  hjdro- 
chloric  acid,  ai'senic,  phosphorus,  and  several  other  blood  poisons.  On  the 
other  hand,  Arthus  proved  that  by  depriving  the  blood  of  its  calcium  it  loses 
its  power  of  coagulation. 

Red,  White,  and  Mixed  Thrombi.— There  are  red,  white,  and  mixed 
thrombi.  The  formation  of  a  white  thrombus  by  an  accumulation  of  white 
blood-cells  can  be  watched  under  the  microscope  by  irritating  with  a  ci'ystal 
of  common  salt  placed  in  its  neighbourhood,  some  large  artery  or  vein  h'ing 
in  the  spread-out  mesentery  or  tongue  of  a  curarised  frog.  At  the  point  of 
irritation  the  inner  wall  of  the  vessel  becomes  covered  with  white  blood-cor- 
puscles, and  a  white  immovable  plug  gradually  develops,  filling  the  entire 
lumen  of  the  vessel  by  a  constant  addition  of  new  white  corpuscles  to  those 
already  in  place.  Some  investigatoi's  claim  that  the  white  thrombi  described 
by  Zahn  are  not  formed  from  white  blood-corpuscles,  but  from  the  blood 
plaques  discovered  by  Bizzozero,  those  very  small,  delicate,  colourless,  disk- 
shaped  bodies  which  constitute  the  thii-d  formed  ingredient  of  the  blood. 
The  origin  of  the  blood  plaques,  which  can  be  stained  with  methyl  violet 
while  in  a  neutral  common-salt  solution,  is  still  obscui'e,  and  their  signifi- 
cance is  still  a  matter  of  controversy.  Eberth  and  Schimmelbusch  make  a 
sharp  distinction  between  the  white  thrombi  of  blood  plaques  and  the  red 
blood-clots;  the  blood  plaques,  according  to  these  authorities,  having  nothing 
to  do  with  the  formation  of  fibrin,  and  simply  adhere  together  at  some  in- 
jured point  of  the  intiraa  as  a  result  of  their  peripheral  location  in  the  blood 
stream  when  there  is  any  marked  retardation  in  the  flow  of  the  current. 
20 


292  INFLAMMATION  AND  INJURIES. 

They  also  hold  that  a  thrombus  is  not  identical  with  a  blood  coagulum,  the 
thrombi  being  not  red,  like  the  ordinary  coagulum,  but  either  entirely,  or  for 
the  most  part,  white. 

Coagulation  of  the  Blood.— There  are  many  views  as  to  the  manner  in 
which  coagulation  of  the  blood  takes  place.  Alexander  Schmidt  and  his  fol- 
lowers, reasoning  from  numerous  experiments,  explain  coagulation  of  the 
blood  in  the  following  manner  :  The  fibrin  results  from  the  union  of  two 
fibrin  generators,  the  fibrinogen  and  the  paraglobulin,  brought  about  by 
the  action  of  the  fibrin  ferment.  The  fibrinogen  exists  in  solution  in  the 
blood  plasma;  the  fibriii  ferment  and  the  paraglobulin  are  first  liberated  by 
the  disintegration  of  the  white  blood-corpuscles,  and  then  have  the  power  of 
acting  upon  the  fibrinogen.  As  long  as  the  white  blood-corpuscles  circulate 
uninjured  in  the  blood  a  coagulum  cannot  form.  In  the  blood  of  birds  and 
amphibia  the  disintegrated  red  (nucleated)  corpuscles  furnish  the  fibrin-mak- 
ing substances.  The  blood  in  immediate  contact  with  the  living  and  normal 
walls  of  a  vessel,  as  we  have  said,  does  not  coagulate ;  but  if  the  walls  are 
altered  by  pathological  processes  or  mechanical  injury — if,  for  example,  the 
intima  becomes  changed  by  inflammation,  if  it  becomes  roughened,  uneven, 
swollen,  torn,  etc. — a  blood-clot  will  form  at  these  points  even  while  the  cir- 
culation still  continues.  Blood  which  has  escaped  from  a  wounded  vessel 
will  immediately  coagulate,  as  will  blood  within  the  heart  or  a  vessel  after 
death.  Moreover,  by  the  disintegration  of  white  blood-cells  which  takes 
place  under  normal  circumstances  in  healthy,  circulating  blood,  some  fibrin 
ferment  develops  (Schmidt,  Jakowicki,  Birk);  this  is  the  case  especially  in 
venous  blood.  It  is  furthermore  an  interesting  fact  that  in  septicaemia  and 
pyasmia  the  amount  of  the  fibrin  ferment  resulting  from  the  disintegration 
of  the  white  blood-corpuscles  can  be  so  increased  as  to  give  rise  to  the  spon- 
taneous formation  of  coagula  (Kohler  and  others).  On  tlie  other  hand,  fever 
is  produced  (Wahl,  Bergmann,  Angerer)  by  the  absorption  of  the  fibrin  fer 
ment  from  the  extravasated  blood  after  operations  or  subcutaneous  injuries 
(fractures). 

Bizzozero,  on  the  other  hand,  ascribes  the  formation  of  fibrin  solely  to  the 
dissolution  of  the  blood  plaques  and  their  derivatives  (Zimmermann's  cor- 
puscles), and  he  denies  that  the  white  blood-corpuscles  have  any  part  in  the 
process.  Haym  also  claims  that  the  cause  of  the  coagulation  of  the  blood 
when  a  vessel  is  injured  is  to  be  sought  for  in  what  he  calls  the  "  haemato- 
blasts"  (Bizzozero's  "blood  plaques").  These  small,  very  easily  altered 
cellular  elements  in  the  blood  become  immediately  changed,  according  to 
Haym,  when  a  foreign  body  comes  into  contact  with  them,  or  when  the  in- 
tima of  the  vessel  loses  its  integrity  by  pathological  processes  or  mechanical 
influences. 

Wooldridge  made  some  very  exhaustive  experiments  vipon  the  subject  of 
coagulation  of  the  blood,  under  Ludwig's  guidance,  in  the  Physiological  Insti- 
tute at  Leipsic,  and  he  states  that  Alexander  Schmidt's  explanation  of  coagu- 
lation of  the  blood  is  correct  only  to  a  very  limited  extent,  if  at  all.  Wool- 
dridge disputes  the  necessity  of  the  co-operation  of  the  formed  elements  of 
the  blood  in  the  process  of  coagulation,  and  asserts  that  the  blood  plasma 
itself,  free  from  all  formed  elements,  contains  everything  which  is  necessary 
for  the  production  of  coagulation.     The  plasma  is  caused  to  coagulate  by  two 


§61.1    ANATOMICAL  PHENOMENA  IN  THE  HEALING  OP  A  WOUND.  293 

bodies  contiiined  in  it,  which  are  a  combination  or  mixture  of  albumen  and 
lecithin,  and  are  called  by  Wooldridge  A-  and  B-fibrinogen.  He  states  that 
certain  substances  (albuminous  bodies  containinj^  a  very  larj^e  percentage  of 
leeithiu)  which  have  a  marked  power  of  producing  coagulation  can  be  iso- 
lated from  the  testicle,  lymph  glands,  the  chyle,  brain,  thymus,  and  stroma 
of  the  red  blood-corpuscles.  He  does  not  attach  any  importance  to  the  fibrin 
ferment  as  a-cause  of  coagulation. 

Our  knowledge  of  the  coagulation  of  the  blood  has  been  recently  en- 
riched by  some  exceedingly  interesting  facts  discovered  by  the  impoi-tant 
investigations  made  by  Marcus  Arthus.*  Arthus  found  that  by  the  addition 
to  the  blood  of  oxalate  of  ammonia — i.  e.,  by  decalcification  of  the  blood — 
the  latter  loses  its  power  to  coagulate ;  but  if  chloride  of  calcium  is  again 
added  in  excess  the  blood  then  immediately  coagulates.  From  this  it  follows 
that  the  calcium  in  the  blood  has  a  fibrinoplastic  action,  and  that  the  fibrin 
ferment  and  the  fibrinogen  only  act  in  the  presence  of  calcium  salts.  Arthus 
states  that  the  salts  of  strontium  have  the  same  effect  as  those  of  calcium, 
and  consequently  there  is  also  a  strontium  fibrin.  This  makes  it  necessary 
for  us  to  recognise  many  different  kinds  of  fibi'in.  Arthus  maintains  that 
the  teachings  of  Schmidt  and  Hammerstein  should  be  modified  to  the  extent 
of  making  three  factors  necessary  for  the  coagulation  of  blood,  viz.,  the  fibrin 
ferment,  fibi-inogen,  and  a  lime  salt.  According  to  Arthus,  the  coagulation 
of  the  blood  is  analogous  to  the  coagulation  of  cheese  from  milk,  the  caseine 
corresponding  to  the  fibrinogen,  the  curdling  ferment  to  the  fibrin  ferment, 
and  the  cheese  to  the  fibrin. 

Freund  maintains  that  the  coagulation  of  the  blood  is  brought  about  by 
the  undissolved  phosphate  of  calcium.  The  phosphates  and  potassium  salts 
preponderate  in  the  blood-corpuscles,  the  sodium  and  calcium  salts  in  the 
serum.  When  the  blood  comes  in  contact  with  a  foreign  body  and  ceases  to 
touch  the  walls  of  the  vessel,  the  phosphates  in  the  blood-corpuscles  unite 
with  the  calcium  salts  in  the  serum,  forming  a  large  amount  of  phosphate  of 
calcium,  which  does  not  all  remain  in  solution. 

The  Varying  Reaction  of  the  Leucocytes  to  Staining  Substances.— The 
colourless  blood-corpuscles  (leucocytes)  vary  in  their  reaction  to  staining 
materials — a  matter  of  great  diagnostic  importance  (Ehrlich).  While  the 
nuclei  of  all  leucocytes  are  coloured  by  the  well-known  aniline  dyes  used 
for  staining  nuclei,  the  protoplasm  of  the  cells  behaves  differently,  possessing 
for  particular  dye  stuffs  a  greater  or  less  affinity.  The  leucocytes  differ  also 
in  size  and  in  the  number  of  their  nuclei  (mono-  or  poly  nucleated).  The  ma- 
jority of  the  leucocytes  (about  seventy  per  cent,  of  the  colourless  blood-corpus- 
cles) form  the  polynucleated  leucocytes,  the  granules  in  which  are  neutral 
(neutrophilar) — i.  e..  their  protoplasm  is  only  susceptible  of  being  stained  by 
neutral  dyes,  such  as,  for  example,  a  neutral  mixture  of  a  basic  and  acid  ani- 
line dye  (methylene  blue  and  the  so-called  acid  fuchsin).  A  smaller  number  of 
the  leucocytes  (about  five  percent,  to  eight  percent.)  in  the  blood  are  eosino- 
philar  or  acidophilar  cells — in  other  words,  the  granules  of  their  protoplasm 
are  capable  of  being  stained  bright  red  by  the  acid  dye  eosin.    The  acidophilar 

*  Marcus  Arthus.  Theses  presentees  a  la  faculte  des  sciences  de  Paris.  Paris  :  H. 
Jouve,  rue  Racine,  15. 


294 


INFLAMMATION  AND  INJURIES. 


or  eosinophilar  granules  are  coarser  than  the  neutrophilar  ;  the  cells  also  are 
perceptibly  larger  than  the  neutrophilar,  and  for  the  most  part  possess  one  or 
two  nuclei  of  considerable  size.  The  third  class  of  leucocytes,  which  are  rare 
— mostly  mononucleated  cells — possess  a  protoplasm  which  is  only  capable  of 
being  stained  by  basic  aniline  dyes  (basophilar  leucocytes).  The  fourth  class 
of  leucocytes,  mostly  small  mononucleated  cells  with  a  narrow  or  broad 
enveloping  band  of  protoplasm,  are  partly  neutrophilar  and  partly  capable  of 
being  stained  by  acid  as  well  as  basic  aniline  dyes  (amphophilar).  Mosso  * 
has  made  an  exhaustive  study  upon  the  change  of  the  red  blood-corpuscles 
into  leucocytes  and  the  necrobiosis  of  the  red  blood-corpuscles  in  coagulation 
and  suppuration. 

Changes  in  the  Thrombus. — After  a  thrombus  has  formed,  the  fur- 
ther points  in  its  history  which  are  of  interest  are  (1)  its  organisation 
into  solid  connective  tissue  containing  blood-vessels,  or,  in  other  words, 
the  formation  of  a  cicatrix,  and  (2)  the  softening  of  the  thrombus. 
The  organisation  of  the  thrombus  into  connective  tissue  containing 
vessels  is  the  most  desirable  termination ;  but  softening  of  the  throm- 
bus, particularly  its  suppurative  breaking  down,  brouglit  about  by  tlie 
action  of  bacteria  and  accompanied  by  subsequent  embolic  processes, 

is  always  dreaded  by  the  sur- 
geon. Thanks  to  the  aseptic 
method  of  operating  and  treat- 
ing wounds,  this  infectious  soft- 
ening or  breaking  down  of  a 
thrombus  is  of  infrequent  oc- 
currence in  modern  surgery. 
We  shall  ti*eat  of  the  infections 
softening  of  thrombi  mord  in 
detail  when  we  come  to  diseases 
of  wounds.  The  calcification  of 
a  thrombus  from  deposition  of 
lime  salts  is  anotlier  compara- 
tively satisfactory  change  whicli 
a  thrombus  may  undergo.  The 
so-called  phleboliths  are  calcified 
thrombi  which  have  formed  in 


Fig.  246. — Ortranisation  of  a  thrombus ;  M,  me- 
dia infiltrated  with  cells ;  -/,  intima  infiltrated 
with  cells ;  i?,  various  shaped  formative  cells 
resultini^  from  the  proliferation  of  the  en- 
dothelial cells  of  the  vessels  and  employed  iu 
the  organisation  of  the  thrombus  ( formation 
of  the  cicatrix  in  the  vessel) ;  7'A,  thrombus. 
X  300. 


veins. 

Organisation  of  the  Thrombus, 
or  rather  the  formation  of  a  Vascular  Cicatrix. — AVe  are  here  concerned 
with  the  question  of  the  organisation  of  the  thrombus  into  connective 
tissue  containing  vessels,  and  in  the  formation  of  a  vascular  cicatrix. 


*  Vircli.  Arch.,  Bd.  109,  1887. 


^61.]    ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.  295 

The  minute  changes  are  practically  the  same  as  we  have  dusci-ibed  above, 
and  they  apply  to  the  arteries  as  well  as  the  veins.  According  to 
Thiersch,  Thoma,  and  others,  the  closure  of  a  vessel,  the  so-called  organ- 
isation of  the  throml)us,  or,  more  correctly,  the  substitution  for  the 
thrombus  of  connective  tissue,  is  mainly  brought  about  l)y  a  prolifera- 
tion of  the  endothelium  of  the  intima.  All  the  authorities  agree  that 
the  thrombus  itself  plays  no  part  in  the  formation  of  a  cicatrix  in  a  ves- 
sel ;  it  is  gradually  supplanted  by  the  cellular  infiltration,  which  then 
forms  fibrillar  connective  tissue.  At  first  variously  shaped  formative 
cells  (Fig.  246)  develop  by  the  proliferation  of  the  endothelium  of  the 
vessels,  and  these  subsequently  change  into  fibrillar  connective  tissue. 
These  cells  penetrate  the  thrombus  in  all  directions  ;  the  connective  tis- 
sue developing  from  them  becomes  steadily  stronger,  and  finally  takes 
the  place  of  the  thrombus  throughout  its  whole  extent.  At  the  conclu- 
sion of  the  process  there  only  remains  of  the  thrombus  a  few  granular 
masses  of  brown  pigment — hsematogenous  pigment,  probably  hydroxide 
of  iron.  Simultaneously  with  this  endothelial  proliferation  and  growth 
of  cells  into  and  throughout  the  thrombus  the  latter  becomes  vascula- 
rised  by  the  formation  of  new  vessels.  If  a  thrombus  does  not  com- 
pletely occlude  the  lumen  of  a  vessel,  its  organisation  takes  a  longer 
time  than  when  the  vessel  is  completely  plugged  by  the  thrombus 
(Baumgarten).  The  cicatrix  is  formed  from  the  cellular  germinal  tis- 
sue in  the  manner  we  have  described  on  page  286.  The  vaseularisation 
of  the  thrombus — i.  e.,  the  formation  of  new  vessels  within  it — takes  its 
start  chiefly  from  the  point  at  which  the  intima  has  been  broken  or 
torn.  The  vasa-vasorum,  on  account  of  the  diminution  of  the  pressure 
in  the  interior  of  the  vessel,  grow  through  the  relaxed  walls  into  the 
lumen  of  the  vessel  (Benecke,  Ackermann). 

The  minute  changes  which  take  place  in  the  organisation  of  a  thrombus 
can  be  studied  very  satisfactorily  by  placing,  with  every  antiseptic  precau- 
tion, a  segment  of  a  vessel  which  has  been  previously  hardened  in  absolute 
alcohol  inside  the  peritoneal  cavity  of  a  rabbit  (Seuf  tleben,  Tillmanns).  There 
will  be  observed  a  steadily  increasing  emigration  of  colourless  blood-corpus- 
cles into  the  wall  and  interior  of  the  vessel,  or  rather  into  the  thrombus  ;  at 
the  same  time  there  will  be  a  corresponding  new  formation  of  vessels  from 
the  germinal  cellular  tissue,  which  is  developed  from  the  endothelium  of  the 
newly  formed  vessels  and  not  from  the  white  blood-corpuscles,  and  finally 
the  thrombus  becomes  supplanted,  in  the  manner  already  described,  by  vas- 
cular fibrillar  connective  tissue,  and  the  vessel  is  closed  by  a  cicatrix  (Fig. 
247). 

The  length  of  time  required  for  the  cicatricial  closure  of  a  vessel  to 
take  place  by  the  organisation  of  a  thrombus  varies  very  much.  In 
young  subjects  the  reparative  process  is  in  general  more  rapid  than  in 


296 


INFLAMMATION   AND   INJURIES. 


old  individuals,  and  it  is  slowest  in  the  case  of  patients  afflicted  with 
chronic  (atheromatous)  degeneration  of  the  intiuia  of  tlie  vessels.     In 

animals  which  have  been  experimented 

■^//r:"^<>ix<.  \^  upon,  vascular  tissue  will  be  found  at 

yu'  "  ^  the   site   of   the  thrombus,   or  rather 

/  .    .'         ,     .  •'  -..^  where  the  ligature  has  been  applied  to 

%  t  '--  /'',,'     '       .       '*-         ^^^G  vessel,  at  the  end  of  the  second 

^^'il'Mff^^  '''   -'-''■~''**'^  •*•  ?  '' '        week,  and  possibly  even  earlier,  by  the 

'**!l-:V^';'''< '^^-tr- >,/*""     *~.  ',       seventh  to  the  eighth   dav.      Durinor 

•'4'*  fe'^i^ '■.'-"■' V V-'' • ,  -  '      •    '      the  third  to  the  fifth  week  the  cicatrix 
'V"  .'jy^-.-.-^l) .'.',  i-'^-^'"-^       ,  •.      .        1  1    ,  ,      , 

;/..•,*-'' -^L  V •J  5*>r-;i^,'    '  ■      m    tlie    vessel    becomes     completely 

Id?*'  '       ~    v^'^^'-i^"*"     «('    '       'j     '         »  .  -T  ./ 

.'■,*'"'  "-^-^'^''/S-'!,    '  S '  >'  formed,    though    in    some    cases    the 

'V        '  ~    '  "^"^   -''  .'/'■,  process  takes  much  longer.     In  course 

>',■  «'^'  of  time  the  cicatrix  in  a  vessel  shrinks 

"-T-'o^-^c    X-i"^  'f '*' ^  ^^^®  ^^J  other  scar.      If  the  cicatrix 

~^-    ^  ""  shrinks   in   the   centre,    the   scar,    or 

Fig.  247. — Ororanised  vascular  thrombus  ,i  .i  i  •       i 

in  a  piece  of  dead  kidney.    Nineteenth      ratllCr    the    veSSCl,    may   agam    bcCOme 
dav.    In  the  centre  are  a  newlv  formed      „^„„i  ii  „i    ii        j:?    „i  ^i. 

blood-vessel  and  a  -iant  cell.    The    pervious,  SO  that  the  linal  rcsult  may 
adventitiaofthe  wall  ofthe  vessel  con-    -j^g  merely  a  diminution  in  the  lumen 

tains  many  leucocytes,  but  the  muscu-  •' 

lar  coat  not  so  many.     Gentian,  Cana-      of    the  VCSScl,  witll  a  thickening  of    itS 

da  balsam.  t  -n        i  i  •  • 

wail.  In  still  other  cases  the  cicatrix, 
as  a  result  of  dilatation  of  the  vessel  in  which  it  lies,  may  become  per- 
forated by  several  small  isolated  vessels  connecting  the  central  and 
peripheral  ends  of  the  artery  (Fig.  249).  The  so-called  sinus  degen- 
eration fRokitanskv),  in  which  the  thrombus  is  chanoced  into  a  network 
of  connective-tissue  strands  having  spaces  between  them,  is  particularly 
liable  to  occur  in  thrombi  which  develop  in  veins. 

Collateral  Circulation. — If  a  blood-vessel — an  artery,  for  example--is 
occluded  at  some  point  by  a  ligature  or  a  thrombus,  a  collateral  circula- 
tion is  immediately  developed  by  dilatation  of  the  vasa  vasorum  and  of 
the  branches  given  off  on  the  proximal  and  distal  side  of  the  thrombus. 
This  restores  the  circulation,  and  ensures  the  nutrition  of  the  portion 
of  the  body  supplied  by  the  occluded  artery  (Fig.  248).  It  is  interest- 
ing to  note  the  manner  in  which  the  collateral  circulation  becomes 
established  after  ligation  of  an  artery  in  its  continuity,  as  illustrated 
in  a  specimen  obtained  by  Luigi  Porta,  showing  the  collateral  cir- 
culation eight  months  after  ligation  of  the  abdominal  aorta  in  a  dog 
(Fig.  249).  ^ 

It  is  plain  that  the  collateral  circulation  took  place  in  this  instance 
both  through  the  dilated  vasa-vasorum  lying  between  the  two  stumps 
of  the  ligated  aorta  and  the  adjacent  lumbar  arteries,  and  branches  made 
up  partly  of  old  and  partly  of  newly  formed  vessels. 


§61.]   ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.   297 

Recently  Xotlniagel  lias  made  some  very  exhaustive  experiments  on 
rabbits  relating  to  the  establishment  of  the  collateral  circulation,  and 
he  found  that  six  days  after  applying  the  ligature  there  occurred  a 
hypertrophy  and  hyperplasia  of  the  muscular  tibres  in  the  dilated  col- 
lateral arteries.  Xothnagel  and  liecklinghausen  explain  the  growth  of 
these  vessels  by  the  increased  rapidity  of  the  blood  current  within  them 
and  the  increased  amount  of  nutrition  which  this  brings  about.     The 


Fig.  248.— Collateral  circulation  Cafter 
ligation  of  an  artery  in  its  conti- 
nuity) through  the  central  and 
peripheral  branches. 


Fig.   249. — Collateral  circulation  eight  months 
after  ligation  of  the  aorta  of  a  dog  (Porta). 


more  blood  that  passes  through  a  vessel  in  a  given  time,  the  greater  is 
the  amount  of  nutritive  material  supplied  to  the  wall  of  the  vessel. 
The  pressure  theory,  which  many  authorities  think  sufficient  to  account 
for  the  establishment  of  a  collateral  circulation,  is.  according  to  Xoth- 
nagel,  of  no  value. 

The  repair  of  a  "Woimd  in  Non-vascular  Tissues. — The  process  of  re- 
pair in  a  wound,  or  the  formation  of  a  cicatrix  in  tissues  which  do  not 
contain  vessels  (cornea,  cartilage,  etc.),  is  practically  the  same  as  for 
vascular  tissue.  "We  know  that  non-vascular  tissues — the  cornea,  for 
example — contain  an  intricate  communicating  system  of  canals,  in 
which,  under  normal  conditions,  wandering  cells  are  present  here  and 
there. 


298  INFLAMMATION   AND   INJURIES. 

If  the  cornea  is  injured  tliere  occurs  an  abundant  emigration  of 
white  blood-corpuscles  from  the  adjoining  sclera  and  conjunctiva  and 
from  the  conjunctival  sac.  The  tissue  developed  from  the  inflamma- 
tion— in  other  words,  the  cicatrix — is  here  also  formed  from  the  origi- 
nal fixed  cells  of  the  cornea. 

A  cicatrix  is  formed  in  cartilage  in  precisely  the  same  way  from  the 
cartilage  cells  in  the  neighbourhood.  The  cicatrix  resulting  from  an 
aseptic  wound — i.  e.,  from  one  which  has  healed  without  reaction — will 
retain  its  fibrillar  character  for  a  great  length  of  time.  Gies  claims 
that  it  retains  this  character  permanently  ;  but  if  a  severe  inflammatory 
reaction  takes  place  the  cicatrix  will  rapidly  become  hyaline,  like  nor- 
mal hyaline  cartilage  (see  Injuries  of  Joints). 

Regeneration  of  Injured  Tissues. — In  every  injured  organ  there  is 
always  an  attempt  to  bring  about,  as  far  as  possible,  a  complete 
restitutio  ad  integrum.  The  regeneration  of  the  damaged  tissues  will 
take  place  the  more  rapidly  and  completely  the  more  delicate  the 
cicatrix  is — in  other  words,  the  stricter  the  asepsis  and  the  more  the 
wound  is  made  to  heal  by  primary  union  without  reaction,  and 
the  less  the  cells  peculiar  to  the  organ  are  damaged.  But  the 
more  highly  organised  tissues  have  relatively  slight  powers  of  regen- 
erating themselves  after  they  have  been  damaged.  The  epidermis,  the 
epithelium  of  the  mucous  membranes,  bones,  cartilage,  periosteum, 
tendons,  and  other  connective-tissue  structures,  are  capable  of  regen- 
erating themselves  completely,  while,  on  the  other  hand,  losses  of  sub- 
stance in  the  various  glands  and  in  muscle  are  not  restored,  but  their 
place  is  supplied  solely  by  scar  tissue,  in  the  manner  descril:»ed  above. 
Consequejitly,  a  cicatrix  M'hich  includes  the  more  deeply  lying  sub- 
cutaneous cellular  tissue  contains  no  sweat  or  sebaceous  glands  and  no 
hair  follicles  or  hairs,  and  a  correspondingly  extensive  cicatrix  in  the 
intestine  contains  no  follicles  and  no  glands  of  Lieberkiihn.  Moreover, 
defects  or  losses  of  substance  in  muscular  tissue  are  only  made  good,  as 
already  stated,  by  scar  tissue,  and  are  not  replaced  by  newly  formed 
muscular  fibres;  the  fibrous  cicatrix  is  interposed  like  a  tendinous 
intersection  in  the  course  of  the  muscle  and  enables  it  to  contract. 
Regeneration  of  muscular  fibre  takes  place  onlj'  in  the  neighbourhood 
of  the  cicatrix,  and  in  those  cases  in  which  the  injury  to  the  muscle  has 
been  trifling — a  contusion,  for  example.  Ponfick,  however,  has  demon- 
strated that  losses  of  sul)stance  in  highly  organised  tissues,  such  as  the 
liver  and  kidneys  of  animals,  can  be  made  good  in  a  relatively  brief 
time  by  a  new  development  of  the  tissues  characteristic  of  the  organ. 

Of  the  more  highly  organised  tissues  the  peripheral  nerves  are  ex- 
ceptional as  regards  their  capability  of  regenerating  themselves.    After 


gGl.J   ANATOMICAL    IMIKXOMENA  IN  THE  llEALlNa  OF  A  WOCND.  299 

a  nerve  has  been  divided  and  neurorrhaphy  performed,  there  will  often 
be  a  complete  rej^eneration  of  the  nerve  even  when  the  neiirorrha])hy  has 
been  performed  several  months,  or  even  a  year,  after  the  reception  of 
the  injury.  Kegeneration  has  been  brought  about  in  a  nerve  in  which 
there  has  been  a  loss  of  substance  several  centimetres  in  length  by 
suturing  together  the  divided  ends  of  the  nerve,  or  by  adopting  otlier 
suitable  measures,  and  now  and  then  even  spontaneously.  I  performed 
a  successful  neuroplasty  upon  the  median  and  ulnar  nerves  for  a  loss 
of  substance  which  they  had  suffered  several  months  previously  (see 
§88). 

Regeneration  of  the  tissues  of  the  brain  and  spinal  cord  never  takes 
place  in  man,  though  Brown-Sequard  has  seen  regeneration  occur  in 
the  divided  spinal  cord  of  a  pigeon. 

The  proper  treatment  for  promoting  regeneration  in  the  various 
tissues  will  be  discussed  in  ii§  87,  88,  101. 

Subsequent  Pathological  Changes  in  the  Cicatrix— Cicatricial  Contraction. 
—  Cicatricial  co)itractures  are  the  most  important  of  the  later  pathological 
changes  which  seal's  undergo.  The  contraction  is,  of  coui-se,  proportionate 
to  the  size  of  the  defect  or  the  amount  of  granulation  tissue.  All  cicatrices 
replacing  losses  of  substance  in  the  skin  and  the  underlying  tissues  are  espe- 
cially liable  to  shrink.  According  to  the  depth  to  which  the  loss  of  sub- 
stance extends,  the  cicatricial  contracture  involves  only  the  skin,  or,  besides 
this,  the  deeper  parts,  esjjecially  the  fascia,  muscles,  and  tendons.  The  cica- 
tricial contractions  following  extensive  burns  are  especially  dreaded.  The 
sequelae  of  such  contractures  vary  with  the  locality  which  is  afPected.  If  one 
is  situated  on  the  flexor  aspect  of  a  joint,  the  latter  will  become  fixed  in  a 
certain  degree  of  flexion  and  cannot  be  completely  extended.  Cicatricial 
shortening  of  the  sterno-mastoid  muscle  causes  wry-neck  (caput  obstipum) ;  a 
scar  involving  the  under  eyelid  will  roll  the  latter  outward  (ectoiJion) ;  cica- 
tricial contracture  of  the  cheek  will  interfere  with  the  opening  of  the  mouth. 
The  chin  and  neck  are  sometimes  fastened  firmly  together  as  a  result  of 
burns.  This  is  not  the  place  to  describe  the  treatment  for  these  conditions, 
and  it  is  only  necessary  to  state  that  they  are  now  treated  with  excellent 
results  by  methods  of  gradual  extension,  or  by  excision  of  the  scar,  followed 
by  implantation  of  Thiersch  skin  grafts,  or  of  flaps  with  pedicles  taken,  per- 
haps, from  a  widely  removed  portion  of  the  body. 

Keloids. — Occasionally  the  cicatrix  becomes  the  seat  of  a  tumour-Uke 
fibrous  induration  called  a  keloid.  A  thick  elevation  develops  at  the  site  of 
the  scar,  usually  with  outgrowths  extending  into  the  adjoining  healthy  tissues. 
This  is  really  a  hypertrophy  of  the  cicatrix.  The  cause  of  this  keloid,  which 
is  rather  rare,  is  not  understood.  After  its  extirpation  there  is  usually  a  re- 
currence. I  saw  one  case  of  cicatricial  keloid  the  size  of  a  plum,  following 
a  perforation  made  in  the  lobule  of  the  ear,  which  resisted  every  kind  of 
treatment  with  the  knife  and  red-hot  iron.  Sometimes  a  keloid  disappears 
by  degrees  spontaneously. 

Malignant  New  Growths. — Occasionally  malignant  new  growths,  like  car- 


300  INFLAMMATION    AND   INJURIES. 

cinomata,  may  originate  in  cicatrices.  We  shall  discuss  this  possibility  when 
we  come  to  the  etiology  of  tumours. 

Cicatricial  Ulcers. — Now  and  then  cicatricial  tissue  breaks  down  and  sup- 
purates, giving  rise  to  a  cicatricial  ulcer,  which  ordinarily  is  covered  with 
large  fungous  granulations  having  no  tendency  to  become  covered  with  skin. 
This  usually  occurs  in  weak  and  sometimes  in  tubercular  incli^^duals,  and  is 
apt  to  start  from  some  slight  injury,  such  as  the  friction  produced  by  clothes 
might  bring  about. 

Pressure  Paralysis  of  Nerves  from  Pressure  of  the  Scar.— A  large  cicatrix 
may  exert  injurious  pressure  upon  the  blood-vessels  in  its  immediate  neigh- 
bourhood, and  may  also  cause  a  pressure  paralysis  of  the  nerves.  It  is  well 
known  that  these  pressure  paralyses  due  to  cicatrices  have,  as  a  general  thing, 
a  favourable  prognosis,  and  will  ordinarily  quickly  disappear  with  removal 
of  the  cause. 

§  02.  The  General  Reaction  which  follows  an  Injury  and  an  Inflamma- 
tion— Fever. — The  general  condition  of  those  who  have  been  injured 
or  operated  upon  bears  a  most  intimate  causal  relationship  to  the  be- 
haviour of  the  wound.  If  the  latter  heals  normally — i.  e.,  aseptically — 
and  if  no  injurious  substances  gain  access  from  the  wound  to  the  cir- 
culating fluids  of  the  body,  there  will  usually  be  no  fever.  From  the 
fact  that  a  wound  which  heals  aseptically,  as  a  rule,  ensures  freedom 
to  the  patient  from  a  general  febrile  disturbance,  it  follows  that  the 
febrile  disturbance  involving  the  whole  system  of  those  who  liave  been 
injured  or  operated  upon  is  mainly  caused  by  the  absorption  from  tlie 
wound  of  injurious  substances,  the  mo.^t  important  of  which  are  the 
micro-organisms  and  the  poisonous  products  of  their  metabolism  held 
in  solution  by  the  fluids  of  the  body.  The  so-called  wound  fever  is 
really  an  absorption  fever — an  alteration  of  the  blood. 

The  fever  which  accompanies  the  so-called  internal  diseases  is  also 
in  part  an  absorption  fever,  and  the  changes  which  are  present  in  the 
blood  and  produced  by  the  bacteria,  or  rather  the  products  of  their  meta- 
bolism (ptomaines,  toxines),  play  a  most  important  part  in  the  causation 
of  the  phenomenon.  On  the  other  hand,  we  must  look  for  the  cause 
of  what  is  called  the  essential  fevers  in  the  central  nervous  .system.  In 
this  latter  class  belong  the  febrile  disturbances  following  a  violent 
fright,  the  periodic  stages  of  excitement  in  mental  disorders,  epileptic 
fits,  injuries  of  the  spinal  cord,  etc.  These  "nervous  fevers"  are  per- 
haps caused  by  an  increa.-ed  metabolism  in  the  tis.sues  due  to  the  ex- 
cessive nerve  irritation,  which  raises  the  temperature  of  the  body,  or'to 
diminished  loss  of  heat  by  radiation  as  a  resnlt  of  the  lessened  rapidity 
of  the  circulation  (Murrij.  The  fever  which  follows  phlebotomy  and 
the  administration  of  cocaine  is,  according  to  Mosso,  also  dependent 
upon  the  nervous  system.     Though  recent  investigations  have  made 


§62.]    REACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    301 

the  etiology  of  wound  fever  so  ))luin  t<j  us,  we  unfortunately  are  still 
iiHU'h  in  the  dark  as  regards  the  nature  of  tlie  febrile  pnjcess.  Tlie 
symptoms  of  fever  are  perfectly  simple,  but  their  explanation  still  pre- 
sents many  insurmountable  difficulties,  and  allows  plenty  of  room  for 
many  hypotheses. 

We  shall  coniine  ourselves  to  the  discussion  of  the  fever  which 
accompanies  surgical  diseases. 

Symptoms  of  Fever. — The  most  important  manifestations  of  any 
fever  are  (1)  the  increase  in  the  temj)erature  of  the  body,  (2)  the  cir- 
culatory disturbances,  and  (3)  the  changed  products  of  the  metabolism 
of  the  body. 

The  Increase  in  the  Temperature  of  the  Body. — The  most  constant 
symptom  of  fever,  and  the  one  which  is  proportionate  to  its  intensity, 
is  the  increase  in  specific  heat.  For  ascertaining  the  temperature  of 
the  body,  we  use  in  Germany  a  thermometer  having  a  scale  divided 
into  one  hundred  parts,  and  each  of  the  one  hundred  parts  subdivided 
into  ten  parts.  The  most  useful  is  the  so-called  maximum  thermometer, 
in  which  the  colunm  of  mercury  maintains  its  altitude  after  the  instru- 
ment has  been  removed  from  the  axilla  or  rectum,  and  readily  permits 
at  any  time  the  reading  off  of  the  higliest  temperature  registered.  The 
temperature  of  patients  who  have  been  injured  or  operated  upon  is  or- 
dinarily taken  in  the  axilla  or  rectum  two  to  three  times  a  day — morn- 
ing, noon,  and  evening.  But  not  infrequently  it  is  important  that  it 
should  be  ascertained  hourly,  or  every  two  hours,  especially  in  cases 
with  high  fever,  in  which  the  height  of  the  fever  decides  the  kind  of 
therapeutic  measures  that  should  be  undertaken. 

If  the  fever  is  slight  the  temperature  in  the  axilla  may  amount  to 
38-5°  to  39°  C.  (101-3°  to  102°  F.) ;  if  severe,  to  40°  C.  (104°  F.) ;  while 
temperatures  above  41°  C.  (104-1°  F.)  or  42°  C.  (106-5°  F.)  are  called  by 
AVunderlich  hyperpyretic.  Unusual  rises  of  temperatures  like  this,  to 
42°  C.  (106'5°  F.)  and  higher,  are  ordinarily  the  precursors  of  a  rapidly 
approaching  death.  Temperatures  higher  than  44-5°  C.  (113°  F.)  are 
very  rarely  observed,  though  Phillipson  has  recorded  the  case  of  a  girl 
twenty-five  years  old  in  whom  the  temperature  reached  47-2°  C 
(116-6°  F.).  Occa.-;ionally  the  temperature  continues  rising  several 
hours  after  the  death  of  the  patient  (post-mortem  rise  of  temperature). 
The  initial  stage  of  fever  is  usually  characterised  by  a  more  or  less 
pronounced  feeling  of  chilliness  or  a  rigour.  This  is  the  more  pro- 
nounced the  more  rapidly  the  fever  rises  and  the  shorter  the  initial 
stage  of  the  fever.  A  chill  is  usually  absent  if  the  body  temperature 
rises  gradually  during  several  days.  During  the  cold  stage  the  tem- 
perature of  the  body  is  already  elevated.     The  cold  feeling  is  the  ex 


302 


INFLAMMATION   AND   INJURIES. 


pression  of  a  nervous  excitation  caused  by  the  difference  in  tempera- 
ture existing  between  the  internal  and  the  external  or  superficial  por- 


Pnls 

Tage :      1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

180 

170 

160 

i:.o 

IW 
130 
120 

no 

100 

.  .      90 

80 

70 

f   u 

f    a 

f\u 

r  a 

r  a 

f 

a 

f 

a 

f 

a. 

f    u 

f    a 

f 

a 

1 41,5 

; 41,0 

I 40,5 

40,0 

, 39.5 

39,0 

1       38.S 
38,0 

37,5 

37,0 
36,5 

\ 
1 

A 

^ 

/ 

t 

1 

/^ 

-/ 

\A 

/ 

\y 

^\ 

s/ 

/ 

1 

t\ 

I 

\r 

j 

J 

' 



__ 

1 — J. 

Fig.  250. — Febris  continua.     Death  on  the  eighth  day. 

tions  of  the  body.  After  the  stage  of  cold  there  follows  the  climax — 
i.  e.,  the  fever  reaches  its  maximum  point.  The  subsequent  course  of 
the  fever  varies.  The  temperature  either  remains  more  or  less  con- 
tinuously elevated  (Febris  continua,  Fig.  250),  or  it  fluctuates  (Febris 
remittens,  Fig.  251).  If  the  fever  is  a  continued  one,  the  difference 
l)etween  the  maximum  and  minimum  rises  of  temperature  taken  in 


Pills 

Tage:      1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

n] 

1        180 
170 
160 
i.-.o 

140 
130 
120 
110 
100 
90 

80 

70 

f   a 

f 

a 

f 

a 

r 

u 

I' 

a 

/' 

a 

f 

CL 

/' 

a 

f 

a 

f 

u 

f 

a 

1 41,5 

, 41,0 

40,5 

40,0 

39,5 

39,0 

38,5 

1       38,0 

_  37.3 

37,0 

36,5 

A 

. 

A 

r 

\  A 

A 

A 

A 

/\ 

I 

M 

\/ 

^\ 

,    / 

/ 

J 

\/ 

V 

r\ 

/ 

V 

V 

V 

V 

''\ 

/ 

\ 

/ 

/ 

\ 

/ 

\^ 

^ 

1 

Fio.  251.— Remittent  type  of  fever  with  gradual  fall  of  temperature  (lysis)  from  the  eighth 

day  on. 

the  course  of  the  day,  or  morning  and  evening,  will  be  at  the  most  but 
a  few  tenths  of  a  degree  (Fig.  250).  In  a  remittent  fever  there  will 
be  a  daily  fall  of  about  1°  C.  (1-8°  F.)  or  more.     A  third  type  of  fever 


§62.]    REACTION  WIIK'II   FOLLOWS  INJURY  AND   INFLAMMATION.   303 

is  the  intermittent,  in  which  brief  marked  rises  in  temperature  alter- 
nate with  normal  or  even  subnormal  temperatures  (Fig.  252).     After 


Puis 

Tage: 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

i   ''    i 

180 
170 
160 
150 

1         1«) 

j         130 

120 

no 

100 
90 
80 
70 

f 

a 

f 

a 

f 

a 

f 

a 

r 

a 

f 

a 

f 

a 

f 

a 

f 

a 

f 

a 

f 

a 

1 41.0 

1 ^0,5 

j 40.0 

1 30.5 

39.0 

1 38.5 

j 38,0 

1  37,5 
; 37.0 

36,5 

1 

h 

A 

h 

i\ 

"/\ 

A 

A 

A 

A 

l\ 

/ 

A 

. 

/  1 

i  /  i  /^ 

. 

r 

l\ 

n 

! 

/ 

y  \/ 

/ ' 

[h 

\ 

/ 

\ 

V 

V 

I 

/^ 

1^ 

J 

V 

V 

\ 

/^ 

\, 

V 

V 

V 

v 

Fig.  2.i2. — Intenuitteut  type  of  fever  with  temporary  sudden  fall  of  temperature  (crisis)  on  the 
fifth  day  ;  fresh  rise  of  temperature  on  the  seventh  day,  and  then  on  the  tenth  day  a  sudden 
fall  of  temperature  followed  by  convalescence. 

each  fall  the  temperature  rises  again  in  the  course  of  the  day,  regularly 
registering  higher  in  the  evening  than  in  the  morning,  or  the  exacer- 
bations may  occur  less  frequently  than  this.  As  we  shall  see  when  we 
come  to  diseases  of  wounds,  the  course  of  the  fever  is  typical  for  many 
diseases,  especially  the  way  that  defervescence  takes  place.  The  decline 
of  the  temperature  may  take  place  rapidly  in  the  form  of  a  crisis,  fall- 
ing 2°  to  3°  to  4°  C.  (3-6°  to  7-2°  F.),  and  even  more  in  a  few  hours  on  a 
single  day  (Fig.  252).  In  such  cases  the  temperature  may  drop  below 
normal  and  become  subnormal,  sometimes  accompanied  by  symptoms 
of  collapse  and  nervous  excitement  (delirium  of  collapse).  In  other 
cases  the  defervescence  comes  on  more  gradually  (by  lysis),  being  for 
several  days  continuous  or  remittent,  with  transient  rises  (Fig.  251). 
The  defervescence  is  usually  accompanied  by  sweating.  After  the  fall 
in  the  fever  thei-e  ensues  the  stage  of  convalescence,  which  is  fre- 
quently only  simulated,  as  a  new  outbreak  of  the  fever  may  take 
place  with  a  set  of  symptoms  exactly  the  same  as  those  which  occurred 
in  the  beginning  (Fig.  252).  Thus,  in  a  protracted  fever  like  chronic 
pyaemia,  the  fever  may  alternate  with  an  apparent  period  of  convales- 
cence, until  death  or  true  convalescence  make  their  appearance.  When 
the  fever  has  a  fatal  termination,  death  may  come  on  during  the  hot 
stage,  and  is  then  often  the  direct  result  of  the  high  temperature;  or 
the  cause  of  death  is  to  be  sought  for  in  the  general  weakening  of  the 
body  brought  about  by  the  fever,  particularly  in  the  degeneration  of 
the  muscles  of  the  heart  and  the  muscular  coat  of  the  blood-vessels, 


304: 


INFLAMMATION  AND  INJURIES. 


and,  above  all,  in  the  general  systemic  poisoning  which  is  due  to  bac- 
teria. The  behaviour  of  the  temperature  curve  is  a  most  important 
diagnostic  guide  for  the  surgeon  in  his  estimation  of  the  condition  of 
the  reparative  process  going  on  in  the  wound,  and  it  enal)les  him  to 
judge  whether  the  dressing  requires  changing  or  not.  Moreover,  the 
surgical  wound  diseases,  as  we  shall  see,  are  characterised  by  a  typical 
fever  curve. 

From  these  facts  it  is  easy  to  understand  the  importance  of  care- 
fully ascertaining  the  body  heat  in  those  who  have  been  operated  upon 
or  injured. 

The  other  symptoms  of  fever  consist  of  disturbances  in  the  circula- 
tion, the  breathing,  the  digestion,  and  the  nervous  system.     They  occur 
as  the  result  of  the  elevated  temperature  or  of  the  primary  disease. 
Behaviour  of  the  Pulse  in  Fever. — Great  importance  attaches  to  the 

condition  of  the 
pulse,  as  regards 
its  frequency,  ten- 
sion, and  regulari- 
ty. Its  frequen- 
cy, in  general,  cor- 
responds to  the 
height  of  the  fe- 
ver, but  exceptions 
to  this  rule  are  not 
infrequent  ;  thus, 
for  example,  as  the 
result  of  stimulat- 
ing the  vagus  or  its  centre  in  the  medulla,  there  occurs  a  slowing  of  the 
pulse  with  an  elevation  of  the  temperature.  In  cases  of  iodoform  pois- 
oning the  temperature  may  be  38°  C.  (100-4°  F.),  while  the  pulse  is 
very  markedly  accelerated.  The  state  of  the  blood  pressure  is  not 
constant  in  fever ;  ordinarily  it  is  somewhat  lower  than  normal  (Lud- 
wig,  Hiiter).  If  the  fever  remains  high  for  any  great  length  of  time, 
the  blood  pressure  becomes  very  decidedly  lessened,  and.  may  give  rise 
to  dangerous  symptoms.  The  pulse  is  often  dicrotic  (Fig.  252,  2) — i.  e., 
it  shows  in  the  place  of  a  single  beat  a  double  one,  caused  by  a  dimi- 
nution of  the  arterial  tension.  A  dicrotic  pulse  can  be  produced  artifi- 
cially in  animals  by  injection  of  atropine  subcutaneously  or  by  adminis- 
tering amyl  nitrite  by  inhalation  (Fig.  253,  3).  The  rapidity  with 
which  the  blood  current  flows,  according  to  the  measurements  taken 
by  Ludwig  and  Iliiter  with  the  sphygniograph,  is  reduced  during  fever 
about  one  third. 


Fig.  2,53.— 1,  Normal  pulse  with  well-marked  arterial  tension;  2, 
dicrotic,  rapid  pulse  in  fever;  3,  very  rapid  dicrotic  pulse  after 
injection  of  atropine  (Meuriot-Marey). 


45(')-2.]    RKACTIOX  WHICH   FOLLOWS  INJURY  AND  INFLAMMATION.    305 

Condition  of  the  Vessels  daring  Fever.— Miira^liano  has  demonstrated, 
with  the  aid  of  Mosso's  i)lethysiii()<irai)li,  that  tlie  cutaneous  l^lood-vessels  are 
contracted  durin<^  fever  hefore  any  rise  in  temperature  can  he  detected  ;  tliat, 
as  the  contraction  of  tlie  vessels  advances,  tlie  temperature  hegins  to  rise,  and 
reaches  its  highest  altitude  simultaneously  with  the  maximum  of  contraction 
in  the  vessels  ;  and  that  the  fall  of  temperature  is  preceded  ])y  a  dilatation  of 
llie  blood-vessels. 

Cheilo-angioscopy. — Hiiter  has  attempted  to  make  a  microscopic  investi- 
gation of  the  circulation  of  the  blood  in  the  lip  of  a  man  suffering  from 
fever.  The  cheilo-angioscope,  as  it  is  called,  which  is  used  for  this  purpose, 
is  described  in  Part  I,  of  Hiiter's  Principles  of  Surgery.  By  means  of  this 
instrument  he  noted  that  in  fever  the  circulation  in  the  smaller  vessels  was 
retarded,  and  finally  that  the  blood  in  them  came  to  a  standstill. 

Condition  of  the  Respiration  during  Fever. — During  fever  the  rpsni- 
ration  is  more  active;  there  is  a  greater  consumption  of  oxygen,  ana 
as  fever  increases,  or,  in  other  words,  metabolism  becomes  more  active, 
there  is  a  larger  atnount  of  carbonic  acid  produced.  According  to 
Kraiis,  twenty  per  cent,  more  oxygen  is  consumed  during  fever  than 
when  the  body  is  in  a  normal  condition.  The  respiration,  particularly 
at  the  beginjiing  of  the  fever,  is  deeper  than  it  ordinarily  is ;  but  later 
on,  after  the  fever  has  persisted  some  time,  it  becomes  sliallower,  on 
account  of  the  weakening  of  the  respiratory  muscles.  If  the  fev^er 
lasts  for  a  long  time,  an  increase  in  the  amount  of  gaseous  interchange 
in  the  lungs  may  not  take  place,  owing  to  the  accompanying  inanition 
of  the  patient. 

Disturbances  of  the  Nervous  System. — The  disturbances  of  the  nerv- 
ous system  during  fever  vslyj  with  the  height  to  which  the  temperature 
rises,  and  with  the  location  of  the  injury.  They  consist  in  a  feeling  of 
general  lassitude  and  debility,  and,  if  the  fever  is  high,  in  a  dulling  of 
the  patient's  intellect,  accompanied  by  all  kinds  of  symptoms  denoting 
irritation  and  depression  of  the  central  nervous  system. 

Digestion. — The  digestion  is  impaired  during  fever ;  tliere  is  pro- 
nounced loss  of  appetite ;  there  is  a  diminution  in  the  amount  of  the 
digestive  juices  secreted,  and  the  peristalsis  of  the  gastro-intestinal  canal 
is  lessened.  Thirst  is  usually  increased,  and  the  tongue  is  apt  to  be 
dry. 

Urine. — The  amoiint  of  urine  secreted  is  diminished,  chiefly  as  the 
result  of  the  lessened  absorption  of  nutritive  matter  and  the  increased 
excretion  of  water  by  tlie  skin  and  lungs.  The  urine  of  a  patient  in 
fever  has  a  high  specific  gravity ;  it  is  rich  in  nitrogenous  substances, 
particularly  urea,  and  in  the  calcium  salts,  and  it  is  poor  in  sodium 
chloride.  The  large  percentage  of  calcium  salts  and  colouring  matter 
is  due  to  the  increased  disintegration  of  the  red  blood-corpuscles  which 


306  IXFLxYMMATION   AND   INJUEIES. 

takes  place  during  fever.  Not  infrequently  the  urine  in  fever  con- 
tains albumen  and  hyaline  casts. 

Muscular  System. — The  symptoms  referable  to  the  muscnlar  system^ 
consisting  of  weakness  and  pain,  are  partly  nervous  in  their  nature, 
being  caused,  in  all  probability,  by  an  altered  innervation,  and  partly 
are  directly  dependent  upon  changes  in  the  muscles  consisting  of  a 
parenchymatous  degeneration  of  their  contractile  substance. 

Body  Weight. — The  weight  of  the  body  diminishes  during  fever,  as 
a  result  of  the  increased  metabolism  or  destruction  of  albumen.  The 
weight  which  a  patient  loses  in  fever  would  be  much  greater  if  the  de- 
struction of  fat  were  in  the  same  ratio  as  that  of  albumen.  According 
to  Kraus,  the  fat  is  not  destroyed  in  the  same  proportion  as  the  albu- 
men. Leyden  has  demonstrated  by  many  systematic  measurements 
that  the  loss  of  weight  is  greatest  during  the  crisis  of  the  fever,  and  in 
twenty-four  hours  at  this  stage  the  average  weight  lost  amounts  to  10-6 
parts  in  l.OOo. 

Prognosis— Outcome  of  the  Fever. — As  Cohnheim  has  correctly 
stated,  the  ho&y  makes  use  of  fever  to  destroy  as  rapidly  as  possible 
the  noxious  substances  which  have  gained  access  to  it.  In  tliis  sense 
fever  is  advantageous  to  the  organism.  It  was  formerly  thought  that 
the  danger  in  a  febrile  disease  lay  mainly  in  the  elevation  of  the  tem- 
perature— in  other  words,  that  death  was  caused  principally  by  the 
abnormally  great  specific  heat.  This  view  is  being  more  and  more  suc- 
cessfully contested.  "We  know  now,  as  regards  the  febrile  diseases,  es- 
pecially those  following  wounds,  that  the  species  of  pathogenic  bacteria 
which  may  be  present,  or  the  products  of  their  metabolism,  are  the  prin- 
cipal factors  in  determining  the  prognosis  of  the  febrile  infection.  The 
length  of  time  which  a  febrile  disease  lasts  may,  aside  from  the  severity 
and  nature  of  the  infection,  become  dangerous  to  the  patient  as  a  result 
of  the  increasing  inanition.  According  to  Leyden,  the  daily  loss  dur- 
ing fever  amounts  to  about  seven  tenths  per  cent,  of  the  total  weight. 
Chossat  states  that  all  the  higher  animals  die  when  they  have  lost  forty 
per  cent,  of  their  weight  through  deprivation  of  nourishment ;  conse- 
quently a  moderately  severe  fever  would  be  sufficient  to  kill  a  man  in 
about  eight  weeks. 

The  Pathological  Changes  during  Fever. — T\\q  pathological  changes 
in  fever  will  be  described  under  the  infectious-wound  diseases,  and 
when  we  come  to  discuss  those  subjects  we  shall  learn  about  the 
changes  in  the  composition  of  the  blood  brought  about  by  micro-organ- 
isms. It  is  sufiicient  to  note  here  that  the  cloudy  swelling,  or  paren- 
chymatous degeneration,  as  it  is  called,  of  the  glands  and  muscles,  varying 
from  a  granular  cloudiness  and  swelling  to  pronounced  fatty  degenera- 


§62.]  REACTION   WHICH   FOLLOWS  INJURY  AND  INFLAMMATION.    307 

tion,  used  to  be  erroneously  looked  upon  as  the  result  of  the  high  tempera- 
ture. Furthermore,  the  loss  of  weight  which  accompanies  a  fever  of  any 
considerable  duration  is  not  the  direct  result  of  the  fever,  but  of  the  in- 
fection or  intoxication  which  has  occurred.  It  is  more  exact  to  ascribe 
all  these  changes  not  to  the  increased  heat  of  the  body,  but  to  the  nature 
of  the  infection  or  poisoning. 

Etiology  and  Character  of  Fever,  particularly  of  Wound  Fever. — If 
we  would  understand  the  etiology  and  nature  of  fever,  we  must  at- 
tempt to  give  an  explanation  of  the  princijml  symptom  of  fever — viz., 
the  rise  of  temperature.  We  have  already  emphasised  the  fact  that 
fever  is  mainly  the  result  of  absorption.  Billroth  and  C.  O.  Weber 
were  the  first  to  add  materially  to  our  knowledge  of  the  etiology  of 
fever,  and  they  demonstrated  that  fever  can  be  caused. in  animals  by 
introducing  into  the  subcutaneous  cellular  tissue,  or  directly  into  the 
blood,  decomposing  animal  or  vegetable  matter.  But  not  only  are 
actually  decomposing  and  putrid  substances  capable  of  causing  fever — 
i.  e.,  pyrogenous — but  also  every  kind  of  pus  due  to  bacterial  infec- 
tion, including  the  so-called  ^m6'  honuni  et  laudahile,  has  the  same  pyro- 
genous effect.  The  micro-organisms  (the  l)acteria)  are  the  most  impor- 
tant of  the  causes  of  fever,  giving  rise  to  it  as  soon  as  they,  or  the  dis- 
solved poisonous  products  of  their  metabolism  (ptomaines,  toxines),  gain 
access  to  the  circulation  (see  §  59).  The  bacteria  act  by  decomposing 
their  nutritive  media,  consisting  of  the  animal  tissues,  the  blood,  and  the 
lymph,  giving  rise  to  fermentative  and  decomposition  processes,  and 
destroying  the  blood-corpuscles,  particularly  the  white  ones,  etc.  We 
learned  in  §  59  that  the  poisonous  products  of  their  metabolism  which 
have  been  isolated  from  the  bacteria  are  also  capable  of  exciting  a  gen- 
eral febrile  intoxication.  Mention  should  also  be  made  of  the  rise  of 
temperature  occurring  in  conjunction  with  constipation,  particularly 
that  following  an  operation,  for  instance.  This  fever  is  probably  due 
to  the  absorption  of  soluble  decomposing  substances  which  are  formed 
either  with  or  without  the  co-operation  of  bacteria.  Every  intoxication 
fever  is  not  by  any  means  to  be  ascribed  to  bacteria,  as  we  know  that 
substances  capable  of  exciting  fever,  such  as  ferments,  can  be  formed 
in  extravasated  blood  and  in  the  undecomposed  secretion  of  a  wound, 
without  the  co-operation  of  bacteria.  We  are  already  familiar  with 
several  ferments  of  this  kind  which  have  the  power  of  producing 
fever,  notably  the  fibrin  ferment  (Alexander  Schmidt),  which  causes  a 
rise  of  temperature  to  take  place  in  the  animal  into  which  blood  has 
been  transfused,  particularly  when  the  blood  is  taken  from  an  animal 
of  another  species.  Hammerstein  investigated  the  blood  of  fifteen 
patients  during  fever,  and  found  fibrin  ferment  existing  in  a  free  state 

21 


308  INFLAMMATION   AND   INJURIES. 

in  the  blood  of  twelve.  He  also  found  it  free  in  the  blood  of  two 
patients  who  did  not  have  fever.  The  presence  of  the  fibrin  ferment 
in  the  blood  during  fever  is  not  constant,  consequently  no  satisfactory 
theory  of  fever  based  upon  the  fibrin  ferment  can  be  established. 
Solutions  of  hemoglobin  algo  have  a  pyrogenous  action — i.  e.,  they  are 
capable  of  exciting  fever.  Schmiedeberg  has  isolated  from  the  blood 
another  ferment,  histocym,  and  has  demonstrated  that  this  body,  which 
is  a  product  of  the  normal  metabolism,  when  introduced  into  the  circu- 
lation in  sufficient  quantities  can  give  rise  to  high  fever.  Bergmann 
and  Angerer  have  shown  that  other  ferments,  such  as  pepsine,  pan- 
creatine, etc.,  have  the  same  power. 

This  non-bacterial  ferment  fever,  as  we  may  call  it,  is  observed 
after  subcutaneous  injuries  of  bones  which  are  accompanied  by  con- 
siderable extravasation  of  blood.  This  is  the  explanation  of  a  rise  in 
temperature,  which  may  reach  39°  to  40°  C.  (102-2°  to  104°  F.),  and 
which  makes  its  appearance  after  a  subcutaneous  fracture,  a  severe  con- 
tusion "of  a  joint,  or  a  subcutaneous  injury  of  soft  parts.  In  the  same 
category  belongs,  perhaps,  the  fever  following  absorption  of  the  unde- 
composed  primary  secretion  of  a  wound,  called  aseptic  wound  fever, 
and  which  may  cause  the  temperature  to  rise  as  high  as  40°  C.  (104°  F.), 
even  when  the  repair  of  the  wound  runs  a  perfectly  aseptic  course 
(Yolkmann  and  Genzmer).  Nevertheless,  I  believe,  at  present,  that  this 
aseptic  wound  fever  is  mainly  the  result  of  a  too  free  use  of  carbolic 
acid  during  the  operation.  If  the  wound  is  much  irritated,  especially 
by  such  an  antiseptic  as  carbolic  acid,  there  will  follow,  not  infrequently, 
extravasations  of  blood  into  the  wound,  there  will  be  a  considerable 
amount  of  secretion,  and  the  above-mentioned  ferments  will  develop  in 
the  stagnant  blood,  and,  even  though  the  wound  remains  aseptic,  these 
ferments  will  give  rise  to  the  so-called  aseptic  wound  fever.  Since  I 
besan  to  use  bichloride  of  mercury  instead  of  carbolic  acid,  and  par- 
ticularly  since  I  began  to  make  less  free  use  of  the  poisonous  antisep- 
tics, I  have  no  longer  observed  this  aseptic  wound  fever. 

Chronic  Ferment  Intoxication.— Langenbeck  and  Cramer  have  recorded 
an  interesting  case  of  chronic  ferment  intoxication  with  continuous  high 
fever,  cough,  and  occasional  diarrhoea  in  a  young  woman  who  had  a  blood 
cyst  the  size  of  a  goose-egg  on  the  thigh.  The  blood  cyst  had  probably  de- 
veloped from  a  pre  existing  cavernous  angioma.  After  its  operative  re- 
moval all  disagreeable  symptoms  immediately  vanished.  Within  the  cyst, 
as  in  all  blood  which  is  not  in  contact  with  the  normal  walls  of  the  vessels, 
or  which  becomes  stagnant,  there  had  developed  different  ferments,  amongst 
them  Schmidt's  fibrin  ferment,  which  had  then  gained  access  to  the  general 
circulation,  as  the  cyst,  from  the  cavernous  structure  of  its  walls,  was  in 
direct  communication  with  the  vascular  system.     The  febrile  symptoms,  and 


§63.]    REACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    309 

the  coagulation  processes  in  the  capillaries  of  the  lungs  and  intestines,  were 
caused  in  this  way,  corresponding  in  every  respect  to  the  facts  which  had 
been  noted  by  Kohler,  Berginann  and  others  in  their  experiments  on  ferment 
intoxication. 

We  are  able,  then,  to  distinguish  two  classes  of  absorption  fever, 
the  first  being  the  fever  caused  bj  micro-organisms  and  the  poisonous 
products  of  their  metabolism  (ptomaines,  toxines)  which  have  gained 
access  to  the  circulation,  and  the  second  being  the  fever  which  follows 
the  absorption  of  the  disintegrated  products  of  the  body,  these  products 
differing  but  little  from  the  substances  formed  in  the  physiological 
metabolism  of  the  body  (non-bacterial  ferment  fever). 

The  part  played  by  the  nervous  system  in  the  production  of  any 
one  of  the  various  kinds  of  fevers  is  briefly  spoken  of  on  page  300. 

Explanation  of  the  Febrile  Process.— How  do  the  factois  so  far  known  to 
be  capable  of  causing  fever,  the  bacteria  and  the  products  of  their  meta- 
bolism, the  non-bacterial  ferments  and  the  central  nervous  system,  how  do 
these  factors  act  ?  in  other  words,  in  what  way  does  the  principal  symptom 
of  fever,  the  rise  in  temperature,  come  about?  It  is  well  known  that  the 
body  temperature  normally  regulates  itself  within  moderate  fluctuations, 
and  that  the  amount  of  heat  formed  and  lost  occasionally  changes  even  in 
health — it  increases  and  diminishes.  The  amount  of  heat  given  off  by  the 
body  is  influenced  by  the  clothing  or  coverings  of  the  body,  by  the  perspira- 
tion, by  the  circulation  of  blood  in  the  skin,  and,  finally,  by  the  increased 
or  diminished  excretion  of  warmth  and  moisture  through  the  lungs.  The 
amount  of  heat  developed  is  altered  by  the  voluntary  or  involuntary  increase 
of  muscular  activity,  by  the  processes  going  on  in  the  glands  and  tissues,  by 
the  ingestion  of  nutritive  material,  or,  in  other  words,  by  the  increased  or 
diminished  supply  of  fuel.  The  nervous  system,  thi^ough  its  reflexes,  regu- 
lates these  various  portions  of  the  apparatus,  causing  each  to  assume  its 
proper  activity,  and  thus  is  explained  the  constancy  of  the  temperature  of 
the  body. 

During  fever  the  amount  of  heat  produced  is,  in  the  first  place,  increased, 
and  the  substances  which  excite  fever  must  somehow  affect  those  parts  of  the 
body  which  regulate  the  production  of  heat.  We  ai-e  ignorant  of  the  exact 
manner  in  which  this  takes  place  during  the  febrile  process.  We  can  only 
say  that  the  physiological  warmth  of  the  body  is  the  product  of  the  biochem- 
ical metabolism  of  the  tissues,  and  the  febrile  agent  causes  an  increased  meta- 
bolism, and  consequently  an  increased  production  of  heat.  It  can  be  proved 
that  the  metabolism  or  combustion  is  actually  increased  during  fever.  The 
increased  consumption  of  oxygen,  the  increased  excretion  of  carbonic  acid 
and  nitrogenous  substances,  particularly  urea,  are  all  evidences  of  the  truth 
of  this.  The  increase  in  urea  corresponds  in  general  to  the  .severity  of  the 
fever,  and,  according  to  Cohnheim,  no  matter  how  little  food  is  administered, 
there  may  be  three  times  more  urea  excreted  than  normally,  and  it  may 
amount  to  forty  to  fifty  grammes  per  diem.  This  increased  secretion  of  urea 
means  that  a  greater  disintegration  of  albumen  is  taking  place  within  the 


310  INFLAMMATION   AND   INJURIES. 

body.  Leyden  gives  the  excretion  of  carbonic  acid  as  one  and  a  half  to  two 
aad  a  half  times  more  than  in  a  state  of  health. 

Are  there  certain  tissues  in  which  the  increased  production  of  heat  is  more 
marked  than  in  others  ?  This  question  has  not  as  yet  been  answered.  We 
only  know  that  muscular  tissue,  particularly  that  of  the  heart,  nerve  tissue, 
and  the  glaads,  are  important  factors  in  the  generation  of  heat.  Mosso  was 
unable  to  demonstrate  in  the  cortex  of  a  dog's  brain  any  circumscribed  cen- 
tre regulating  the  heat  of  the  bodj^  but  he  conjectured  that  the  regulating 
power  was  widely  distributed  throughout  the  brain  and  spinal  cord.  Aron- 
son,  Sachs  and  Gottlieb  aflBrm  that  the  heat  centre  for  rabbits  exists  in  the 
corpus  striatum. 

The  blood  is  certainly  one  of  the  most  important  sources  in  which  a  rise 
of  temperature  in  fever  takes  place,  and  this  is  particularly  true  in  wound 
fevers,  where  it  contains  bacteria  and  the  dissolved  poisonous  products  of 
their  metabolism.  By  the  latter's  presence  in  the  circulation  we  know  that 
the  blood  becomes  altered  and  that  the  white  blood-corpuscles  are  destroyed. 
It  is  probable  that  the  increased  metabolism  and  the  lise  of  temperature  are 
the  results  of  the  alteration  in  the  blood,  since  the  heart  and  the  walls  of  the 
vessels  are  directly  affected  by  the  noxious  substances,  particularly  the  dis- 
solved poisonous  products  of  bacterial  metabolism.  Consequently  Bergmann 
has  advanced  the  view,  and  it  seems  to  me  to  be  the  correct  one,  that  the 
cause  of  the  febrile  rise  of  temperature  is  to  be  sought  for  in  an  increased 
metabolism  in  the  blood.  The  alterations  in  the  blood,  according  to  Berg- 
mann, are  the  most  essential  of  all  the  accompaniments  of  fever.  In  order 
to  retain  the  constancy  of  the  composition  of  the  blood,  all  the  machinery  in 
the  body  designed  for  this  purpose  exhibits  a  more  intense  activity,  and  in 
this  way  is  explained  the  increased  metabolism  and  rise  in  temperatia-e 
which  occurs  in  fever.  On  account  of  the  elevated  temperature  of  the  blood 
the  further  development  and  spread  of  certain  species  of  pathogenic  bacteria 
are  prevented.  It  is  a  fact  that  in  anthrax  infection,  for  example,  the  animal 
affected  has  only  to  be  repeatedly  cooled  off  to  make  the  bacilli  appear  imme- 
diately in  the  blood.  The  fever  or  elevation  of  the  temperature  of  the  body 
and  the  gi'eater  activity  of  its  metabolism  is  all  a  conservative  process  which 
the  body  makes  use  of  to  more  rapidly  get  rid  of  the  injurious  substances 
which  have  gained  access  to  it. 

In  other  cases,  where  there  is  no  intoxication  or  infection  of  the  blood  or 
tissues,  the  rise  in  temperature  is  due  to  influences  connected  with  the  nerv- 
ous system,  as  we  have  before  remarked. 

Loss  of  Heat  during  Fever. — What  are  the  conditions  as  regards  the 
amount  of  heat  lost  during  fever  ?  Ordinai-ily  the  amount  of  heat  lost  dur- 
ing the  chill  is  less  than  normal,  but  during  the  height  of  the  fever,  ac- 
cording to  Leyden's  measurements,  it  is  greater,  being  for  temperatures  above 
40°  C  (104°  F.)  double  the  normal,  and  even  triple  when  there  is  an  abun- 
dant secretion  of  sweat.  Nevertheless  the  body  is  unable  to  get  rid  of  its  ex- 
cess of  warmth,  becai^se  the  amount  of  heat  produced  is  continuously  increased 
during  fever,  whilst  the  amount  lost  fluctuates,  at  one  time  being  greater 
than  normal,  and  at  another  less.  The  diminution  in  the  amount  of  heat 
lost  is  due  to  the  contraction  of  the  cutaneous  blood-vessels,  which,  as  we  saw 
on  page  301,  begins  before  the  rise  in  temperature. 


§63.]    REACTION  WHICH  P^OLLOWS  INJURY  AND  INFLAMMATION.    311 

Traubc,  particularly,  taii<jlit  that  the  cause  of  fever  was  to  be  found  in  the 
diminished  amount  of  heat  lost,  or  rather  in  the  patholof^^ical  changes  con- 
nected with  the  loss  of  heat.  It  is  more  correct  to  ascribe  the  cause  of  fever  to 
the  increased  production  of  heat  resulting  from  the  more  active  metabolism, 
in  conjunction  with  a  pathological  alteration  in  the  amount  of  heat  lost. 
Tlie  amount  of  heat  lost  is  not  constant,  as  Traube  thought,  but  it  is  patho- 
logically altered,  being  at  one  moment  increased  and  at  another  decreased. 
Traube  was  wrong  in  denying  an  increased  production  of  heat  in  fever. 

Definition  of  the  Febrile  Process. — If  we  should  wish  to  formulate  a 
definition  of  the  febrile  process,  we  can  say,  with  Recklinghausen,  that 
fever  is  a  disturbance  which  increases  the  metabolism  of  the  materials 
of  the  body,  especially  the  tissues  which  are  rich  in  albuminous  sub- 
stances. This  increased  metabolism  may  have  its  cause  in  the  nervous 
system  or  in  the  blood.  Recklinghausen  considers  that  the  part  of  the 
system  principally  affected  by  fever  is  the  motor  apparatus  of  the  vas- 
cular system,  consisting  of  the  heart  and  muscular  coat  of  the  vessels 
which  are  regulated  by  the  vasomotor  nervous  system.  The  latter 
plays,  according  to  Recklinghausen,  one  of  the  most  important  parts  in 
the  production  of  fever.  The  typical  symptoms  of  fever  result  from  a 
combination  of  excitation  of  the  nervous  and  vasomotor  apparatus, 
with  an  increase  in  the  biochemical  processes  carried  on  by  the  tissues 
of  the  body,  due  to  certain  causes.  The  exciting  cause  of  the  fever 
leads  to  molecular  changes  in  the  body  substances,  but  how  this  comes 
about  still  baffles  us. 

Treatment  of  Fever. — We  shall  confine  ourselves  to  the  treatment  of 
wound  fever.  It  is  mainly  surgical,  and  consists,  in  the  first  place,  in 
properly  treating  the  existing  injury.  The  best  prophylactic  measures 
in  the  treatment  of  wound  fever  consist  in  carrying  out  strictly  the 
rules  of  antisepsis  and  asepsis.  It  is  very  important  to  provide  for  the 
escape  of  secretions  from  the  wound  by  means  of  careful  drainage.  If 
fever  makes  its  appearance  in  a  patient  who  has  been  wounded  or  op- 
erated upon,  it  is  advisable  to  examine  the  wound  carefully  to  deter- 
mine whether  there  is  a  retention  of  the  secretion  or  some  other  ab- 
normity. In  wounds  which  have  been  sutured,  which  involve  the  scalp, 
for  instance,  it  may  be  sufficient  to  remove  the  sutures  and  permit  a 
free  escape  of  the  retained  secretion,  and  the  fever  will  thus  often  dis- 
appear very  promptly.  In  other  cases  deep  incisions  may  have  to  be 
made  on  account  of  the  retention  of  secretions,  and  abundant  drainage 
may  be  necessary.  I  make  it  a  rule  to  change  the  dressings  on  patients 
who  have  been  injured  or  operated  upon  if  the  temperature  rises  above 
38'5°  C.  (101*3°  F.).  If  the  wound  is  really  aseptic,  as  in  fresh  in- 
juries, or  after  operations,  healing  without  fever  is  usually  assured. 


312  INFLAMMATION  AND   INJURIES. 

The  different  wound  diseases  due  to  infection  must  receive  their  special 
treatment  (see  ^§  66-82).  If  the  temperature  becomes  too  much  ele- 
vated, or  if  the  duration  of  the  fever  threatens  to  cause  serious  weak- 
ness of  the  patient,  in  addition  to  the  above  brieflj  outlined  local  treat- 
ment of  the  wound,  it  is  advisable  to  adopt  other  suitable  means  of 
treating  the  fever,  just  as  in  ordinary  febrile  diseases.  The  best  way 
of  reducing  the  temperature  when  there  is  no  conti-aindication  consists 
in  the  employment  of  cool  baths,  cold  packs,  and  sponging  off  with 
cold  water. 

The  cold-water  treatment  of  fever  is  considered  by  many  physicians 
the  best  means  at  our  disposal  for  reducing  the  temperature.  It  is  used 
either  in  the  form  of  baths  at  a  temperature  of  20°  C.  {()S°  F.),  in 
which  the  patient  is  immersed  for  ten  minutes,  or  baths  at  a  tempera- 
ture of  24:°  C.  (75'2°  F.),  which  are  gradually  cooled  down  during 
fifteen  to  twenty  minutes  to  a  temperature  of  22°  C.  (71*8°  F.).  At 
the  same  time,  in  proper  cases  cold  water  is  poured  over  the  patient, 
or  even  ice  water,  as  he  lies  in  the  tub.  This  serves  as  an  excellent 
stimulant  to  respiration  and  the  psychical  functions.  The  patient  is 
then  brought  back  to  bed  without  being  previously  dried  off,  as  in 
this  way  the  cooling  off  will  continue  longer.  Wine  should  be  admin- 
istered freely  as  a  stimulant  while  the  patient  is  being  subjected  to 
this  treatment.  The  reduction  of  temperature  by  medicaments,  such 
as  quinine,  digitalis,  veratrum  viride,  sodium  salicylate,  antipyrine,  etc., 
should  be  employed  when  the  patient  caimot  stand  cold  baths,  or  when, 
for  some  reason  or  other,  their  use  is  not  practicable. 

The  action  of  the  antifebrile  medicaments,  such  as  antipyrine,  has 
been  repeatedly  tested  in  recent  times,  and  it  has  been  proved  that  they 
act  principally  through  the  nervous  system,  particularly  the  vasomotor 
part  of  it,  and  the  heat  centres  in  the  l)rain  ;  they  increase  the  amount 
of  lieat  lost,  or  they  diminish  the  amount  of  heat  produced,  or  they  do 
both.  Maragliano  demonstrated  that  kairine,  antipyrine,  thalline,  qui- 
nine, and  salicylate  of  sodium,  whether  administered  during  fever  or  in 
health,  caused  dilatation  of  the  cutaneous  vessels,  and  thus  increased  the 
amount  of  heat  lost  by  radiation. 

The  best  treatment  by  the  surgeon  of  wound  fever  consists  in  a 
careful  investigation  of  the  wound,  and,  as  far  as  possible,  in  remedying 
any  abnormity  which  may  exist.  The  treatment  of  tlie  rise  in  tem- 
perature, if  present,  is  next  to  be  considered,  though  it  will  generally 
not  be  necessary  to  do  more  than  to  rectify  any  abnormal  condition 
which  may  be  found  in  the  wound.  At  present  antijiyresis — i.  e.,  the 
reduction  of  elevated  temperatures — is  not  so  energetically  carried  out 
as  it  used  to  be  even  in  medical  cases.     Lately  we  have  been  giving  up 


§63.]  SHOCK.  313 

more  and  more  the  idea  that  the  temperature  curve  is  the  only  consid- 
eration which  determines  our  treatment  of  fevers.  Repeated  observa- 
tions have  demonstrated  that  thei*e  is  no  trutli  in  the  idea  that  man  can- 
not survive  an  elevation  of  the  specific  heat  of  his  body  al)Ove  42°  C. 
(107"G°  F.).  Striimpell  and  others  have  declared  that  the  reduction  of 
the  increased  body  temperature  should  not  form  the  only  part  of  our 
treatment  of  fevers.  A  routine  treatment  of  fever  is  not  a  good  plan. 
Every  case  must  be  treated  sym])tomatically,  according  to  the  condi- 
tions which  may  arise.  Too  energetic  antipyresis — i.  e.,  the  adoption 
of  too  active  measures  for  reducing  temperature — can  frequently  do 
more  harm  thaii  good,  from  the  fact  which  we  mentioned  before, 
viz.,  that  the  temperature  of  the  body  must  be  higher  than  normal  to 
render  possible  the  sudden  or  gradual  destruction  of  many  species  of 
bacteria  ;  and  if  the  temperature  of  the  body  is  lowered,  infection  of  the 
blood  is  favoured. 

It  is  wise  to  give  patients  who  have  fever  easily  digestible  food,  and 
to  restrict  its  amount  and  variety.  Cool,  effervescing  waters  with  citric 
acid,  fruit  juices,  and  wines  should  be  allowed  as  drinks.  If  an  indi- 
vidual has  been  accustomed  to  the  "use  of  alcohol,  the  latter  should  not 
be  denied  him  entirely,  as  otherwise  nervous  complications,  or  even  de- 
lirium tremens,  may  make  their  appearance  (see  §  G4).  Furthermore, 
it  is  known  that  alcohol  has  the  power  of  directly  reducing  temperature,  j  / 

§  63.  Shock. — By  shock  is  understood  a  peculiar  state  of  depression 
of  the  nervous  system,  which  is  apt  to  be  excited  reflexly  by  injuries 
involving  a  shaking  up  or  contusion  of  the  sensory  nerves. 

Etiology  of  Shock, — Fischer,  Goltz,  and  Seabrook  consider  the  es- 
sence of  shock  to  be  a  paralysis  of  the  vasomotor  centre  in  the  medulla 
oblongata,  produced  reflexly  by  a  contusion  or  violent  disturbance  of 
the  sensory  nerves  in  the  manner  illustrated  by  Goltz's  well-known 
experiment  on  the  frog.  By  repeatedly  striking  the  abdomen  of  a 
frog  there  is  produced  a  peculiar  state  of  collapse,  which  can  tei-minate 
fatally  by  cardiac  paralysis,  the  heart  stopping  in  diastole.  The  cause 
of  these  phenomena  lies  in  the  fact  that  by  mechanical  irritation  of 
the  intestines,  or  the  irritation  of  any  sensory  nerves,  the  activity  of 
the  brain  and,  above  all,  of  the  vasomotor  centre  in  the  medulla  ob- 
longata, becomes  reflexly  altered,  weakened,  or  paralj'sed.  As  a  result 
of  this  there  follows  a  diminution  or  paralysis  of  the  vascular  tone,  par- 
ticularly in  the  arteries.  There  is  a  weakening  in  the  propelling  force 
driving  on  the  stream  of  blood,  the  speed  of  the  current  lessens,  and 
the  blood  pressure  diminishes ;  the  blood  is  unequally  distributed,  the 
arterial  system  is  less  full,  the  lungs  and  brain  are  anaemic,  while,  on 
the  other  hand,  the  blood  collects  in  the  veins,  particularly  those  in  the 


314  INFLAMMATION   AND   INJURIES. 

abdomen.     Eventually  the  disturbances  in  the  circulation  may  become 
so  pronounced  that  the  heart's  action  ceases. 

Seabrook  attempted  to  determine  the  nature  of  shock  by  experiments  on 
animals,  making  contusions  of  the  tissues  in  both  warm-  and  cold-blooded 
species,  and  he  reached  the  same  conclusion  that  has  been  given  above. 
He  determined  by  his  experiments  that  external  violence,  acting  through 
the  sensory  nerve  trunks,  so  aflFected  the  medulla,  and  the  vasomotor  centre 
in  particular,  that  after  a  brief  period  of  irritation  a  condition  of  depression 
followed  which  resulted  in  a  permanent  dilatation  of  the  blood-vessels.  The 
inhibitory  nervous  system  of  the  heart  plays  only  an  unimportant  part  in 
shock,  except  when  the  terminal  branches  of  the  vagus,  as  in  Goltz's  beating 
experiment,  are  directly  acted  upon  by  the  violence  causing  the  sbock.  The 
paralysis  of  the  vasomotor  centre  is  sufficient  for  explaining  all  the  symp- 
toms which  are  manifested  by  patients  in  a  condition  of  shock.  By  the  pa- 
ralysis of  the  muscular  coat  of  the  smaller  arteries  the  blood  current  loses 
part  of  the  force  by  which  it  is  propelled,  the  blood  flows  more  slowly,  and, 
following  the  law  of  gravitation,  sinks  into  the  vessels  which  are  most  de- 
pendent, particularly  the  large  abdominal  veins.  Thus  not  only  do  these 
become  distended  witb  blood,  but,  in  addition,  the  right  heart  soon  becomes 
overloaded  ;  the  heart's  action  is  interfered  with,  the  pulse  grows  weak,  fre- 
quent, and  small.  The  abnormal  distribution  of  the  blood,  the  anaemia  of 
the  skin  and  the  brain,  due  to  the  overfilling  of  the  abdominal  veins,  cause 
the  paleness,  the  coolness  of  the  superficial  portions  of  the  body,  and  the  cere- 
bral symptoms,  somnolence,  and  motor  weakness. 

Symptoms  of  Shock. — The  sum-total  of  the  symptoms  of  shock  in 
man  correspond  exactly  to  the  facts  which  have  been  determined  ex- 
perimentally. All  the  manifestations  of  shock  can  be  traced  back  to 
the  paralysis  of  the  vasomotor  nerves  produced  reflexly  by  the  con- 
tusion of  the  sensory  nerves. 

Tlie  charaGteristic  symptoms  of  shock  are  a  marked  pallor  and 
coolness  of  the  skin  and  visible  mucous  membranes ;  the  face  is  with- 
out expression  ;  the  eyes  are  dull  and  staring,  the  pupils  are  dilated, 
and  react  slowly.  The  heart's  action  is  plainly  delayed,  irregular,  and 
weak ;  the  pulse  is  thready  or  imperceptible ;  the  respiration  is  irregu- 
lar and  long ;  deep  breaths  alternate  with  shallow  inspiratory  efforts. 
The  mind  is  dull  and  reacts  slowly ;  the  patients  are  completely  apa- 
thetic, and  will  only  answer  questions  tardily  and  unwillingly.  The 
sensibility  of  the  superficial  portions  of  the  body  is  impaired,  and  the 
energy  of  muscular  movement  is  diminished.  Not  infrequently  there 
is  nausea  or  actual  vomiting.  The  temperature  is  about  1°  to  1^° 
C.  (1*8°  to  2*7°  F.)  below  the  normal.  In  other  cases,  instead  of  the 
above-described  torpid  form  of  shock,  there  will  be  a  more  active  set 
of  symptoms — in  other  words,  the  patients  are  more  excited,  they  fling 
themselves  about,  cry  out,  shriek,  and  act  like  maniacs. 


§63.]  SHOCK.  315 

It  is  undoubtedly  true  that  shock  occasionally  changes  gradually 
into  deep  syncope  and  ends  in  death,  particularly  in  the  case  of  neuro- 
pathic, anicniic  individuals.  In  such  cases  there  will  usually  be  found 
complicated  injuries  with  severe  loss  of  blood,  and  the  post-mortem 
examinations  will  frequently  show  that  there  are  also  severe  internal 
injuries,  perhaps,  of  the  brain.  As  a  general  rule,  patients  suffering 
from  uncomplicated  shock  will  recover  after  the  lapse  of  a  longer  or 
shorter  time,  ordinarily  after  a  few  hours.  Sometimes  a  psycliical 
change  persists  for  a  certain  length  of  time,  but  eventually  perfect  re- 
covery will  take  place.  All  nervous  manifestations,  syncope,  etc., 
which  follow  severe  losses  of  blood  and  which  may  look  very  much 
like  shock,  should  be  carefully  distinguished  from  true  shock  (see 
§§  87-89). 

The  individual  symptoms  of  shock,  particularly  cerebral  shock,  will 
be  described  in  the  Special  Surgery  under  Concussion  of  the  Brain. 
The  latter  injury  may  cause  the  patient  to  lose  more  or  less  completely 
all  recollection  of  the  accident.  He  may  not  be  able  to  remember 
how  he  was  hurt,  he  may  have  no  idea  of  distance  and  time,  and  may 
even  forget  everything  he  did,  saw,  or  heard  for  several  days  before 
the  time  of  his  injury.  As  the  circulation  in  the  brain  becomes  in 
time  gradually  restored  and  regulated,  the  patient  may  recover  some 
of  his  lost  memories,  but  a  part  of  his  experiences,  recollections,  and 
conceptions  will  I'emain  lost  forever. 

The  Treatment  of  Shock, — The  treatment  of  shock  consists,  in  the 
main,  in  overcoming  as  soon  as  possible  the  existing  paralysis  of  the 
vasomotor  nerves,  together  with  the  accompanying  disturbances  which 
the  paralysis  gives  rise  to.  To  combat  effectively  the  cerebral  anaemia, 
the  head  of  the  patient  should  be  placed  low  down  ;  but  if  venous  con- 
gestion of  the  face  becomes  marked  this  position  of  the  head  must  be 
immediately  given  up.  Fischer  and  Ivonig  are  right  in  recommend- 
ing vigorous  stimulation  of  the  skin  by  sinapisms,  electricity,  rubbing 
the  extremities,  applying  dry  heat,  etc.  In  fact,  Goltz's  beating  ex- 
periment fails  if  combined  with  vigorous  irritation  of  the  sensory 
nerves  of  the  extremities.  Internally  warm  stimulating  drinks,  strong 
coffee,  hot  wine,  whiskey,  etc.,  should  be  administered ;  there  should 
also  be  given  subcutaneous  injections  of  camphor  or  calabar  extract, 
digitalin,  and  atropin.  Tincture  of  digitalis  can  be  tried  by  mouth 
instead  of  subcutaneous  injections  of  digitalin.  Dercum  has  highly 
recommended  the  rectal  use  of  a  musk  emulsion  (0*9  to  1"25  gramme), 
with  fifteen  drops  of  the  tincture  of  opium  or  an  enema  of  strong, 
black  coffee.  The  respiration  must  be  carefully  watched,  and,  if  neces- 
sary, kept  up  artificially,  as  described  in  §  13.     One  must  avoid  under- 


316  INFLAMMATION   AND   INJURIES. 

taking  an  operation  with  cliloroform  narcosis  upon  a  patient  in  a  state 
of  shock.  The  chloroform  narcosis  niaj  alone  be  sufficient  to  cause 
the  weakly  contracting  heart  to  come  to  a  complete  standstill.  Patients 
who  are  suffering  from  shock  should,  as  a  rule,  not  he  operated  upon  ; 
but  if  it  is  absolutely  necessary  to  adopt  some  operative  measures,  such 
as  checking  hsemorrhage  or  the  like,  the  operation  should  be  done 
without  chloroform. 

§  64:.  Delirium  Tremens. — By  delirium  tremens  (drunkard's  delirium) 
is  understood  an  acute  outbreak  of  chronic  alcoholic  poisoning,  which 
is  particularly  liable  to  occur  when  a  habitual  drinker  is  compelled, 
by  some  injury  or  acute  internal  disease,  to  remain  for  some  time  in 
bed.  Delirium  tremens,  owing  to  the  increase  in  the  misuse  of  alcohol, 
has  been  observed  in  youthful  subjects,  and  even  in  five-  to  eight-year- 
old  children.  These  children,  whose  parents  had,  as  a  rule,  been  ad- 
dicted to  drink,  had  for  a  long  time  been  taking  daily  increasing  amounts 
of  alcohol.  The  delirium  usually  breaks  out  very  soon  after  the  injury 
or  operation.  According  to  Ivrugenberg,  in  about  fifty  per  cent,  of  the 
cases  there  exists,  besides  the  alcohol  habit,  a  tendency  to  some  nerv- 
ous disease  such  as  epilepsy.  Krugenbei-g,  basing  his  opinion  on  three 
hundred  and  one  cases  of  alcoholism  which  he  ol)served,  amongst  which 
tliere  were  one  hundred  and  sixty-one  eases  of  delirium  tremens,  denies 
that  the  sudden  stoppage  of  alcohol  plays  a  causative  part  in  the  pro- 
duction of  delirium  tremens. 

The  first  syrnjytohis  manifested  are  loss  of  sleep,  great  restlessness, 
and  constant  talking.  The  trembling  movements  are  characteristic, 
and  particularly  evident  when  the  patient  is  told  to  hold  out  his  arm 
or  to  show  his  tongue.  Tlie  patients  see  animals  of  every  description, 
and  they  are  very  a})t  to  complain  that  their  rest  is  disturbed  by  mice, 
rats,  etc.,  crawling  about  them.  The  delirium  is  generally  connected 
with  marked  hallucinations,  and  not  infrequently  there  is  pronounced 
maniacal  excitement.  They  try  to  get  up,  and  they  may  even  walk 
about  without  pain  though  they  have  a  fracture  of  the  leg.  They  make 
frequent  attempts  to  run  away,  and  consequently  must  be  carefully 
watched.  Very  often  they  will  have  to  be  put  in  a  strait-jacket  and 
tied  in  bed.  The  prognosis  of  the  delirium  is  in  general  favourable, 
though  it  frequently  happens  that  old  people,  in  particular,  die  rather 
suddenly  with  symptoms  of  collapse.  It  must  also  be  borne  in  mind 
that  the  original  injury  from  which  such  a  patient  may  be  suffei'ing — 
a  subcutaneous  fracture,  for  example — may  easily  run  an  unfavourable 
(complicated)  course  if  his  violent  movements  are  not  carefully  enough 
guarded  against,  and  he  is  not  properly  treated.  The  post-mortem  ex- 
amination will  usually  reveal  the  ordinary  changes  which  occur  in  the 


J5  65.]     DKLIRIUM   NERVOSUM   AND   PSYCHICAL  DISTURBANCES.      31 Y 

organs  of  drunkards,  particularly  chronic  gastritis,  atheromatous  degen- 
eration of  the  arteries,  fatty  liver,  the  kidneys  of  Bright's  disease, 
thickoiiing  of  tlie  oorel)ral  ineiiibranes,  etc. 

Treatment  of  Delirium  Tremens. — The  treatment  of  delirium  tremens 
consists,  in  the  first  place,  of  vigorous  prophylactic  measures.  It  is 
exceedingly  important  that  the  daily  amount  of  alcohol  which  the 
patient  has  been  accustomed  to  should  not  be  stopped,  and  even  more 
alcohol  should  be  given  during  his  illness  than  he  is  accustomed  to  take 
normally.  In  this  way  an  outbreak  of  delirium  tremens  can  often  be 
avoided.  Considerable  amounts  of  alcohol  should  be  administered, 
best  in  the  form  of  strong  wine  or  cognac — about  one  half  to  three 
quarters  to  one  litre  in  twenty-four  hours;  and,  in  addition,  the  patient 
should  be  given  an  easily  digestible  diet — meat,  bouillon  with  eggs,  etc. 
Furthermore,  it  is  a  good  plan  to  administer  opium  in  large  doses  (O'lO 
to  0-40  gramme  every  two  hours),  with  or  without  combining  it  with 
Rochelle  salts,  or  opium  with  chloral  hydrate,  or  morphine  subcu- 
taneously,  to  combat  the  restlessness  and  loss  of  sleep  from  which  the 
patient  suffers.  I  do  not,  as  a  general  thing,  like  these  narcotics  in  the 
treatment  of  delirium  tremens,  and  prefer  large  doses  of  alcohol,  which 
will  often  bring  on,  without  the  assistance  of  narcotics,  the  sleep  which 
is  the  precursor  of  a  speedy  convalescence.  I  employ  opium  or  mor- 
phine only  in  bad  cases  of  great  restlessness  or  mania.  "When  the  latter 
condition  is  present,  it  is  an  excellent  plan  to  use  cold  douches,  continued 
for  a  considerable  length  of  time,  until  the  patient  is  put  to  bed  in  an 
exhausted  condition. 

Sawadskje  praises  the  action  of  strychnine,  which  he  exhibits  in 
doses  of  0-003  gramme  for  a  week,  to  counteract  the  desire  for  drink, 
and  as  a  treatment  of  the  delirium  tremens  and  the  conditions  which  it 
gives  rise  to. 

§  65.  Delirium  Nervosum  and  Psychical  Disturbances  which  may  fol- 
low Injuries  and  Operations. — By  delirium  nervosum  is  understood  a 
condition  of  nervous  excitement  without  fever  (Billroth),  which  is 
sometimes  observed  in  hysterical  persons,  following  injuries  and  opera- 
tions. The  delirium  may  be  of  the  wild,  maniacal  type,  or  it  may  be 
melancholic.  Some  cases  have  the  character  of  hysteria,  or  dementia 
senilis.  The  delirium  of  sepsis,  alcoholism,  and  poisoning  from  iodo- 
form, morphine,  chloroform,  and  of  uraemic  states,  etc.,  of  course  do 
not  belong  to  this  class.  Le  Dentu  has  noted  over  twelve  cases  of 
delirium  nervosum  following  operations,  and  he  lias  collected  sixt}-- 
eight  cases  from  the  literature  on  the  subject,  thirty-eight  of  which 
were  observed  after  operations  on  the  female  genitalia.  Delirium  ner- 
vosum generally  makes  its  appearance  two  to  five  days  after  the  opera- 


318  INFLAMMATION  AND  INJURIES. 

tion,  and  lasts  several  days  or  a  week,  and  in  exceptional  cases  may 
terminate  in  death  (Le  Dentu).  In  tlie  majority  of  instances  the  psy- 
chical disturbances  occurring  in  connection  with  operations  upon  the 
male  and  female  sexual  organs,  or  following  operations  upon  the  face, 
etc.,  are  of  a  transient  nature.  Mention  should  also  be  made  of  the 
delirium  of  collapse,  which  is  occasionally  observed  after  a  sudden  fall 
of  a  high  temperature — for  instance,  after  the  defervescence  in  ery- 
sipelas, and  in  hysterical  individuals  with  a  subnormal  temperature. 
This  delirium  of  collapse  is  usually  accompaTiied  by  transient  psychical 
disturbances.  The  prognosis  of  collapse  delirium  is  generally  favour- 
able, and  the  acute  mental  aberration  often  disappears  in  a  few  days, 
or  even  in  a  few  hours. 

§  QQ.  The  Infectious -Wound  Diseases. — The  existence  of  infectious 
diseases  of  wounds  has  been  established  beyond  a  question  by  the 
labours  of  Pasteur,  Billroth,  Klebs,  Eberth,  and,  above  all,  by  Koch 
and  his  followers.  Thanks  to  their  careful  researches,  we  now  know 
that  the  infectious  diseases  of  wounds  are  caused  by  micro-organisms, 
or  by  the  products  of  their  metabolism  (ptomaines,  toxines).    (See  §  59.) 

Koch,  experimenting  upon  animals,  excited  infectious-wound  dis- 
eases which  possessed  many  similarities  to  corresponding  diseases  in 
man.  However,  the  facts  which  are  experimentally  ascertained  as 
regards  animals  cannot  be  directly  applied  to  man,  as  we  know  that 
different  species  of  animals  are  affected  differently  by  the  same  poisons. 
A  poison  or  a  certain  species  of  bacteria  may  not  be  injurious  for  one 
kind  of  animal,  while  this  same  poison  may  immediately  excite  danger- 
ous symptoms  in  another.  Furthermore,  totally  different  classes  of 
micro-organisms  may  produce  in  different  animals  diseases  which  are 
very  similar.  The  bacillus  of  mouse  sepsis  is  totally  different  from 
the  bacillus  which  causes  sepsis  in  rabbits,  and  it  does  not  cause  sepsis 
in  the  latter.  The  sepsis  which  occurs  in  mice  from  infection  by  a 
bacillus  has  only  been  observed  in  house-mice,  while  field-mice  are 
immune  from  its  effects,  etc. 

Koch  was  the  first  to  develop  an  exact  method  for  investigating 
the  infectious  diseases  of  wounds.  He  introduced  improved  methods 
of  illuminating  and  staining  preparations,  and  thus  made  it  possible 
for  us  to  study  the  shape,  distribution,  and  number  of  the  l)acteria  in 
the  body.  He,  moreover,  made  cultures  of  the  bacteria  which  he  had 
found  upon  solid  nutritive  media,  so  as  to  observe  the  characteristics 
of  their  growth  and  the  immutability  of  their  species.  These  pure 
cultures  were  then  reinoculated  upon  animals,  for  the  purpose  of  ex- 
citing the  same  disease  which  they  had  first  caused.  We  have  these 
exact  methods  of  his  to  thank  for  our  knowledge  of  the  etiology  of  the 


g66.]  THE   INFECTIOUS- WOUND   DISEASES.  319 

infections  diseases  of  wonnds,  and  the  facts  ascertained  by  experiments 
upon  animals  conform  very  closely  to  what  we  have  ol)served  in  man. 

Every  iuHammatory  or  sn])[)urative  process  which  occurs  in  the 
wound,  such  as  circumscribed  and  diffuse  cellulitis,  acute  inflamma- 
tions of  the  lyyijth  and  blood-vessels  (lymphan<ritis,  phlebitis,  arteritis), 
erysi[)elas,  hospital  gangrene  (wound  diphtheria),  j)yaMnia,  septicasmia, 
and  tetanus,  are  all  included  amongst  the  secondary  infectious  diseases 
of  wounds  which  may  make  their  appearance  in  man.  These  infec- 
tious-wound diseases  are  all  caused  by  bacteria.  This  class  of  diseases 
also  inchides  anthrax,  hydrophobia,  glanders,  etc.,  which  are  diseases 
communicated  from  animals  to  man.  .  Actinomycosis,  tuberculosis,  and 
syphilis  are  also  due  to  infection  by  micro-organisms,  and  there  are  still 
other  diseases  of  a  like  character  which  we  shall  learn  about  later.  The 
bacteria  are  capable  of  gaining  access  to  the  tissues  or  the  fluids  of  the 
body  through  any  wound,  even  the  smallest  interruption  in  the  con- 
tinuity of  the  skin  or  mucous  membranes.  The  trauma  in  itself 
plays  no  part  in  the  origin  of  the  infectious-wound  disease,  and  the 
gravest  injuries,  the  most  extensive  operations,  will  run  their  course 
without  intlannnation  and  without  suppuration,  provided  only  the  bac- 
teria are  kept  out  of  the  wound.  The  best  way  of  preventmg  an  in- 
fectious-wound disease  is  to  employ  the  most  careful  asepsis  or  anti- 
sepsis in  every  operation  or  injury  and  in  the  application  of  every 
dressing.  The  possibilities  of  surgery  since  the  introduction  of  anti- 
septic and  aseptic  methods  have  increased  to  a  most  wonderful  degree, 
and  our  responsibility  towards  our  patients  lias  become  correspondingly 
greater.  Every  physician  should  constantly  bear  in  mind  that  he  may 
cause  the  death  of  his  patient  by  a  single  transgression  of  the  lules  of 
asepsis — by  an  unsterilised  and  non-aseptic  instrument,  or  by  an  unclean 
finger. 

The  infectious  diseases  of  wounds  have,  corresponding  to  the  action 
of  the  bacteria,  partly  a  local  and  partly  a  general  systemic  character. 
As  was  stated  in  §  62,  the  general  disturbances,  the  fever,  and  the  gen- 
eral poisoning  are  caused  by  the  absorption  of  the  metabolic  products 
of  the  fungi,  which,  as  we  shall  see  when  we  come  to  septicaemia,  can 
give  rise  to  systemic  poisoning  even  after  they  have  become  separated 
from  the  fungi.  Their  metabolic  products  thus  give  rise  to  an  intoxi- 
cation which,  like  every  kind  of  poisoning  by  chemical  substances,  can- 
not be  transmitted  by  inoculation.  Infectious  diseases  caused  by  the 
bacteria  themselves  are,  on  the  contrary,  capable  of  being  transmitted 
from  one  individual  to  another.  We  shall  see  that  each  one  of  the  in- 
fectious-wound diseases  to  which  man  is  subject  is  excited  by  a  specific 
micro-organism.     There  are  cases,  however,  which  are  not  due  to  in- 


320  INFLAMMATION   AND   INJURIES. 

fection  by  any  single  species  of  bacteria,  but  are  mixed  infections — in 
other  words,  they  are  caused  by  several  different  species  acting  together. 
The  questions  concerning  the  signiiicance  of  the  micro-organisms  in 
the  causation  of  the  infectious-wound  diseases  and  the  various  methods 
for  investigating  them  have  been  described  in  §  59. 

In  all  febrile  infectious  diseases  of  bacterial  origin  the  cause  of  tlie 
fever  is  to  be  ascribed  to  the  changes  in  the  blood  brought  about  by 
the  bacteria,  or  ratlier  the  products  of  their  metabolism.  Furthermore, 
in  the  fevers  due  to  unformed  ferments,  or  non-bacterial  solutions,  such 
as  fibrin  ferment,  pepsin,  trypsin,  or  haemaglobin,  it  is  principally,  as 
described  in  §  62,  the  change  in  the  composition  of  the  blood  which 
gives  rise  to  the  increased  oxidation  processes  going  on  in  the  blood, 
and  to  the  rise  of  temperature. 

§  CT.  Inflammation  and  Suppuration  of  a  Wound — Etiology. — Though 
it  was  once  believed  that  all  suppuration  was  caused  by  micro-organisms, 
we  learned  on  page  240  that  Grawitz,  De  Barry  and  others  have  dem- 
onstrated that  suppuration  can  also  be  excited  without  bacteria  in  dogs 
and  rabbits  by  aseptic  (germ-free)  chemical  substances,  such  as  turpen- 
tine, nitrate  of  silver,  mercury,  etc. 

Moreover,  sterilised  cultures  of  various  micro-organisms,  or  the 
sterilised  products  of  their  metabolism  (cadaveriiie,  putrescine,  penta- 
methylendiamine),  have  a  similar  (pyogenic)  power  of  exciting  suppu- 
ration. When  Behring  added  iodoform  to  the  cadaverine  the  latter 
never  produced  suppuration. 

Though  it  is  undoubtedly  true  that  suppuration  can  be  excited  b}^  a 
whole  series  of  germ-free  chemical  substances,  it  is  just  as  certain  that 
suppuration  is  produced  in  man,  under  ordinary  conditions,  by  the 
presence  and  life  of  certain  distinct  micro-organisms,  no  matter  whether 
the  suppuration  takes  the  form  of  a  simple  felon,  a  furuncle,  or  a  dan- 
gerous phlegmon.  The  question  does  not  involve  two  opposing  prin- 
ciples, since  the  bacteria  themselves  give  rise  to  suppuration  mainly 
through  the  chemical  products  of  their  metabolism.  Ogston,  Rosen- 
bach  and  others  have  studied  the  micro-organisms  which  are  present 
in  acute  suppuration,  and  they  have  frequently  found  only  a  single 
species,  but  at  other  times  several.  Suppuration  in  man  is  mainly  due 
to  cocci,  which  are  found  either  in  irregular  masses  arranged  in  groups 
(the  staphylococcus.  Fig.  254),  or  in  the  form  of  chains  (the  strepto. 
coccus.  Fig.  256).  The  streptococcus  is  more  apt  to  give  rise  to 
spreading  erysipelatous  inflammations,  the  staphylococcus  to  localised 
inflammation  and  suppuration,  and  the  latter  is  the  true  pus  coccus. 
The  lodgment  of  pus  cocci,  or  rather  the  starting  up  of  suppuration,  is 
favoured  by  local  lesions  as  well  as  by  weakness  of  the  whole  organism. 


t5  67.]  INFLAMMATION    AND   SUPPl'IiATION   OF   A   WOUND.  321 

Different  Kinds  of  Pus  Microbes.— Ogston,  Rosenbacli  and  Passct  have 
made  pure  culturos  of  tlii'  various  bacteria  found  in  acute  suppuration  upon 
solid  nutritive  media  (peptone-gelatine-meat  extract,  nieat-peptone-agar,  hard- 
ened blood  serum,  potatoes).  Rosenbach  has  cultivated  five  different  spe- 
cies of  microbe.s  winch  lie  obtained  from  thirty  acute  abscesses,  leaving 
out  the  ab.scesses  which  contained  decomposing  matter  and  were  filled  with 
bacilli,  si)iril]a,  and  various  kinds  of  cocci  in  addition  to  the  pus  cocci. 
Amongst  these  five  kinds  of  microbes  Rosenbach  found  one  species  only 
once,  an  oval  coccus  (bacterium).  The  others  were  the  staphylococcus  pyo- 
genes aureus,  the  staphylococcus  pyogenes  albus,  the  micrococcus  pyogenes 
tenuis  (rare),  and  the  streptococcus  pyogenes.  Passet  cultivated  eight  differ- 
ent kinds  of  pus  microbes— the  staphylococcus  aureus,  albus,  and  citreus; 
the  streptococcus  pyogenes,  a  micro  organism  resembling  the  pneumococcus; 
the  bacillus  pj'ogenes  fcetidus  (Fig.  259)  ;  the  staphylococcus  cereus,  and 
flavus.  They  are  all  capable  of  exciting  acute  suppuration.  The  cultures 
of  the  chain  cocci  of  pus  cannot  be  distinguished  from  the  cocci  of  ery- 
sipelas (see  §  71).  From  Passet's  experiments  it  ajipears  that  the  effect  upon 
animals  of  the  pus  streptococci  is  almost  exactly  the  same  as  the  effect  pro- 
duced by  the  cocci  of  erysipelas.  All  the  microbes  found  in  foci  of  suppu- 
ration, when  transplanted  into  milk  will  cause  the  latter  to  coagulate.  The 
fact  that  pyogenic  microbes  may  in  one  instance  cause  only  trifling  suppura- 
tion, in  another  a  dangerous  diffuse  phlegmon,  which  may  thi-eaten  life,  and 
in  still  another  an  acute  inflammation  of  the  bone  marrow  (osteomyelitis),  or 
pyaemia  with  its  metastases,  is  explainable  partly  by  the  differences  in  the 
points  of  invasion  and  partly  by  the  variability  in  the  numbers  and  virulence 
of  the  micro-oi'ganisms  which  gain  access  to  the  system.  While  suppura- 
tion is  going  on,  pus  cocci  can  frequently  be  demonstrated  in  the  blood, 
virine.  and  sweat  (Brunner,  Tizzoni,  etc.). 

Artificially  obtained  Immunity  from  the  Poison  of  Pus  Cocci. — In  excep- 
tional cases  the  pus  of  acute  suppuration  does  not  contain  any  microbes, 
though  this  does  not  necessarily  mean  that  none  have  been  present  at  an 
earlier  period,  since  we  know  from  Rosenbach's  experiments  that  there 
are  bacilli  which  c^use  suppiu'ation  and  then  perish  very  soon  afterwards. 

Lindwurm  and  Pazet.  sixty  years  ago,  recorded  a  temporary  immunity 
from  poisoning  by  pus  cocci  in  animals,  brought  about  by  the  injection  of 
pus.  P.  Reichel  has  obtained  temporary  immunity  in  dogs  from  the  vinas 
of  pus  cocci  by  injecting  into  their  peritoneal  cavities  pure  cultures  of  the 
staphylococcus  pyogenes  aureus  or  by  inoculating  them  with  the  germ-free 
infiltrate,  or  products  of  the  metabolism  of  the  staphylococcus  pyogenes  au- 
reus.    This  immunity  was  of  very  brief  duration,  la.sting  only  a  few  weeks. 

Effects  of  Bichloride  upon  Pus  Cocci.— According  to  Abbot,  bichloride  of 
mercury  is  capable  of  rendering  harmless  only  a  certain  number  of  pus  cocci 
(staphylococcus  pyogenes  aureus)— sometimes  more  and  sometimes  less— de- 
pending upon  the  virulence,  or  rather  the  resisting  powers,  of  the  cocci. 

The  Most  Important  Pus  Microbes.— 1.  The  staphylococcus  pyogenes 
aureus  (Figs.  254,  255),  so  designated  because  of  its  golden  or  orange-yellow 
colouring  matter,  is  the  species  of  micrococcus  which  is  most  frequently 
found  in  suppuration.  (According  to  Frankel,  it  is  found  in  eighty  per  cent. 
of  all  the  cases  examined).     These  cocci  are  incapable  of  motion,  vary  in  size, 


322  INFLAMMATION  AND  INJURIES. 

and  are  arranged  in  clusters,  often  in  the  form  of  diplococci.     It  is  present 
in  pus,  in  the  air,  in  dish-water,  and  in  the  earth.     The  staphylococcus  pyo- 
genes aureus  can  be  grown  in  pure  cultures 
upon  gelatine,  agar-agar,  potatoes,  and  blood- 
serum.     In  gelatine  plate  cultures,  at  the  end 
of  the  second  day,  small  punctiforra  colonies 
appear,  having  a  yellow  colour  and  a  sharp, 
slightly    depressed   border,    separating   them 
from  the  non-fluid  gelatine.      Puncture  cul- 
tures in  gelatine  at  first  reveal  a  dim,  greyish 
point,  which  after  about  three  days  becomes 
yellowish,   and    then   orange-coloured ;   then 
the  gelatine  becomes  liquefied,  and  the  culture 
Fio.254.-Puswithst5iylococcus     ^hiks  to  the  bottom.      Linear  cultures  upon 
(Flugge).     x800.  agar-agar  (Fig.  255)  give   an   opaque  yellow 

culture  which  has  a  crooked  outline.  Upon 
potatoes  there  first  forms  a  thin,  whitish  layer,  which  gradually  becomes 
orange-yellow,  and  smells  like  paste.  The  staphylococcus  pyogenes  aureus 
grows  in  blood  serum  in  the  same  way  as  upon  agar-agar.  All  cultures  de- 
velop pretty  rapidly— most  so  at  temperatures  between  30°  and  37°  C.  (98'6° 
F.),  and  more  slowly  at  ordinary  room  temperatures.  They  have  not  hitherto 
been  seen  to  form  spores.  This  coccus  possesses  great  powers  of  retaining 
its  vitality,  and  is  exceedingly  resistant,  for  instance,  to  drying,  chemical 
substances,  and  boiling  water.  To  the  latter  it  has  to  be  subjected  for  several 
minutes  before  it  is  killed.  The  staphylococcus  pyogenes  aureus  can  exist  a 
great  while  without  atmospheric  air,  is  facultative  aerobic,  and  gives  rise  to 
the  formation  of  no  gas  or  stinking  decomposition ;  it  peptonises  albumen 
and  liquefies  gelatine.  Gram's  method  is  excellent  for  staining  the  staphy- 
lococcus pyogenes  aureus. 

The  pathogenic  eflPect  of  the  staphylococcus  pyogenes  aureus,  when  used 
experimentally  upon  animals,  varies  with  the  manner  in  which  it  is  em- 
ployed. Inoculations  have  been  made  upon  man  by  various  experimenters. 
Garre  inoculated  himself  by  inserting  a  pure  culture  in  a  small  wound  at  the 
root  of  his  finger-nail,  and  obtained  an  extensive  suppuration  ;  by  rubbing  a 
great  number  of  the  cocci  upon  the  healthy,  unbroken  skin  of  his  forearm  he 
produced  a  large  cai-buncle.  Subcutaneous  inocvilations  in  mice,  guinea-pigs 
and  rabbits  are  without  any  result,  though  subcutaneous  injections  in  the 
two  latter  classes  of  animals  give  rise  to  the  formation  of  abscesses.  Injec- 
tions made  into  the  peritoneal  cavity  cause  a  violent  suppujative  inflamma- 
tion, which  usually  kills  the  animal  in  a  few  days.  Injections  of  the  cocci 
into  the  blood-vessels  give  rise  to  inflammations  of  joints  and  to  diseases  of 
the  kidneys,  and  metastatic  abscesses  develop  in  the  muscles  of  the  heart  and 
in  the  kidneys.  If  the  valves  of  the  heart  are  first  wounded,  a  typical  endo- 
carditis ulcerosa  results.  If,  before  injecting  the  cocci  into  a  blood-vessel,  a 
subcutaneous  fracture  or  crush  of  one  of  the  long  hollow  bones  is  artificially 
produced,  the  point  at  which  the  injury  is  situated  becomes  "  predisposed"  to 
suppurative  inflammation  of  the  medullary  portion  and  periosteum.  The 
staphylococcus  pyogenes  aureus  is  the  most  frequent  excitant  of  acute  osteo- 
myelitis  (see  §  104).     Frequently    the   staphylococcus   pyogenes   am-eus   is 


67.] 


INFLAMMATION    AND   SUPPURATION   OP   A    WOUND. 


323 


fouud  combined  with  other  niicro-orgauisnis  iu  cases  of  suppuratiou.  Arti- 
ficially acquired  immunity  from  the  poison  of  the  staphylococcus  pyogenes 
aureus  is  described  on  pajje  1121. 

2.  The  staphylococcus  pyogenes  albus  is  in  all  respects  similar  to  the 
staphylococcus  pyogenes  aureus,  except  in  not  having  the  latter's  yellow  col- 
ouring matter.  It  also  appears  to  be  somewhat  le.ss  harmful,  and  is  of  less 
frequent  occurrence  than  the  aureus. 

3.  The  staphylococcus  pyogenes  citreus  was  discovered  by  Passet,  and  is 
seldom  found  in  suppurative  processes  in  man.    The  staphylococcus  pyogenes 
citreus  is  distinguished  by  its  beautiful  lemon-yellow  pig- 
ment (Fig.  2.'?2),  but  is  otherwise  exactly  like  the  aureus 

and  albus,  except  that  it  takes  longer  to  liquefy  gelatine.  ■    / 

Streptococcus  Pyogenes. — 4.  The  streptococcus  pyo- 
genes (Fig.  250)  plays  a  very  important  part  in  the  causa- 
tion of  suppuration.  It  is  frequently  found  alone  in  ab- 
scesses, rarely  in  combination  with  the  staphylococci. 
This  coccus  causes,  for  the  most  part,  progressive  suppura- 
tion, and  from  recent  discoveries  is  thought  to  be  identi- 
cal with  Fehleisen's  streptococcus  of  erysipelas.  In  the 
latter  disease  the  streptococcus  is  found  principally  in  the 
lymph  channels  of  the  skin.  The  streptococci  form 
chains  generally  consisting  of  six  to  ten  to  twenty  cocci 
arranged  in  a  row  like  links,  though  there  may  be  hun- 
dreds of  these  cocci,  or  links,  in  a  single  chain.  The 
chains  are  often  made  up  of  two  parts,  or  they  may  be 
twisted  together  in  thick  masses,  or  arranged  in  slender 
bundles.  The  following  are  the  principal  facts  as  regards 
the  development  of  pure  cultures  :  Gelatine  plate  cultures 
take  the  form  of  fine,  round,  granular  dots.  Linear  cul- 
tures upon  gelatine  plates  are  thickest  at  the  centre  of 
the  line,  of  a  faint  brown  colour,  with  the  edges  of  the 
line  plainly  punctate,  and  later  becoming  graded  off  in 
terraces.     Puncture,  or  stab  cultures,  in  gelatine,  have  a  I 

delicate  areola  at  the  point  where  the  puncture  enters  the  I 

gelatine,  the  line  of  puncture  itself  being  finely  granular 
(Fig.  257).  The  streptococcus  does  not  multiply  upon 
potatoes,  though  some  individual  cocci  increase  in  size,  />  I 

and,  when  examined  by  the  microscope,  chains  are  seen  ''^M 

made  up  of  some  large  and  some  small  cocci  or  links. 
The  streptococcus  pyogenes  grows  best  at  a  temperature 
of  35°  to  37°  C.  (98-6°  F.),  ordinary  room  temperatures  be- 
ing less  favourable  to  them.     The  cultures  grow  slowly, 
linear  cultures  requiring  two  to  three  weeks  to  spread  a 
couple  of  millimetres.     After  the  lapse  of  four  months 
the  cultures  will  be  found,  for  the  most  part,  to  have  perished.     Gelatine  is 
not  liquefied  ;  it  decomposes  albumen  in  a  vacuum;  it  is  facultative  aerobic, 
and  is  not  particularly  affected  by  the  absence  of  oxygen.     It  is  best  stained 
by  Gram's  method.     The  streptococcus  pyogenes  c^n  be  found  almost  any- 
where, and  its  pathogenic  effects  may  be  manifested  in  various  ways,  accord- 


FiG.  255. — Linear  cul- 
ture in  agar-agar — 
Staphylococcus  py- 
rosrenes  aureus. 


324: 


INFLAMMATION   AND   INJURIES. 


7 


Fio.  256.- 


Streptococcus,  x  950 : 
coccus. 


ft,  pus  with  strepto- 


iiig  to  the  manner  and  the  region  in  which  it  gains  access  to  the  body.  It  is 
found  in  saliva,  nasal  and  vaginal  mucus,  and  in  the  urethra  of  man  iu 
health.     It  is  often  found  in  tissues  which  have  undergone  morbid  changes 

— for  example,  in  typhoid 
fever,  pneumonia,  tuberculo- 
sis, pleurisy,  and  scarlet 
fever,  and  under  such  condi- 
tions it  may  give  rise  to  se- 
vere inflammatory  complica- 
tions. Upon  the  valves  of 
the  heart  it  excites  typical 
endocarditis.  When  grow- 
ing in  the  lymph  channels 
of  the  skin  and  mucous  mem- 
branes it  causes  cutaneous 
erysipelas  and  destructive 
inflammation  of  the  mu- 
cous membranes,  and  when  lodged  in  the  subcutaneous  tissue  it  gives  rise  to 
cellulitis,  etc. 

Bacillus  Pyocyaneus.— 5.  The  bacillus  pyocyaueus  a,  Gessard,  or  the  ba- 
cillus of  green  or  blue  pus,  is  a  small  slender  rod  (Fig.  258)  sometimes  found 
in  a  non-suppurating,  serous  wound  secretion  and  in  ordinary 
sweat.  This  bacillus  gives  to  pus  or  dressings  a  blue  or  gi-een 
colour  without  causing  complications  to  arise  in  the  reparative 
process  in  the  wound,  and  is  similar  to  the  bacillus  of  blue 
milk.  Though  somewhat  narrower,  it  is  capable  of  active  mo- 
tion, and  frequently  takes  the  form  of  a  string  with  four  to  six 
joints,  and  less  often  forms  long  filaments.  It  has  not  been 
observed  to  undergo  spore  formation.  When  cultivated  on 
gelatine  plates,  small  white  points  or  dots  make  their  appear- 
ance within  the  gelatine,  gradually  rising  to  the  surface,  upon 
which  they  spread  out.  The  nutritive  medium  very  soon  takes 
on  a  greenish,  fluorescent  colour  all  around  the  culture,  and 
after  the  lapse  of  about  five  days  the  gelatine  becomes  com- 
pletely liquefied.  In  a  test  tube  the  bacillus  develops  almost 
exclusively  in  the  deepei-  parts  of  a  stab  culture.  The  gelatine 
becomes  rapidly  liquefied,  and  assumes  a  beautiful  green  col- 
our. Upon  agar-agar  there  forms  a  moist,  rather  thick  yellow 
covering,  which  colours  the  nutritive  medium  green.  Upon 
potatoes  there  is  developed  a  dirty  yellowish -green  scum,  with 
a  green  discolouration  of  the  adjoining  parts.  The  colouring 
matter  (pyocyanine)  is  for  the  most  part  seen  at  the  free  bor- 
ders of  the  clusters,  and,  according  to  Ledderhose,  is  an  aro- 
matic crystalline  compound  having  no  j)athogenic  properties. 
According  to  C.  Frankel,  the  coloui'ing  matter  is  white  when 
first  formed  from  the  bacteria,  only  assuming  its  peculiar  tinge 
when  brought  in  contact  with  the  oxygen  of  the  air.  The  bacilli  themselves, 
and  the  products  of  their  metabolism,  are  undoubtedly  injurious  to  animals. 
If  about  one  cubic  centimetre  of  a  fresh  bouillon  culture  is  injected  into  the 


r ; 

1 

' 

''ji^ 

!'\ 

Iu 

t\ 

Si 

r 

5' 

Fig.  257.— Star 
or  puncture 
culture  of 
streptococcus 
pyogenes. 


4^67.]  INFLAMMATION  AND  SUPPURATION  OP  A   WOUND.  325 

subcutaneous  tissue  of  a  guinea-i)ifi^  or   rabbit   there  will    result  a  rapidly 
spreading  cedenia  and  suppurative  iuflauimation,  causing  the  death  of  the 
animal  in  a  short  time.     The  bacilli  will  be  found  at  the 
point   of  iuoculatitm   in  the   blood  and   internal   organs.  .^iVii^'IivV'' 

Boucluird  and  Charrin  have  demonstrated  the  very  inter-     'V   ^"^^!j)^5~    N 
estinj;  f;u?t  that  it  is  i)ossible,  with  the  aid  of  the  bacillus     ^^,  ''/'•i'x»'a>' ,  ^j  ^• 
pyocyaneus,  to  check  an  advancing  anthrax  infection  and      '"^^  ^(({fi  '  \^'I, 
to  cause  it  entirely  to  disappear.  *    '^-^ 

Bacillus  Pyocyaneus  ,:<  Ernst.— Ernst  has  described  a  ^'o-  258.— Bacilli  of 
variety  of  the  bacillus  pyocyaneus  as  the  /ii  bacillus  pyocy-  xTOO.''^  ^v  ^^ 
aueus.  It  forms  a  blue  colouring  matter,  or  rather  blue 
pus,  while  the  other  («)  bacillus  forms  the  green  pigment.  Ledderhose  has 
designated  the  a  bacillus  the  bacillus  pyofluorescens,  and  /3  bacillus  the  ba- 
cillus pyocyaneus  3.  Grenerally  the  two  kinds  of  bacilli  occur  together  and 
produce  a  mixed  colour. 

Other  Colouring  Matters  Produced  by  Bacillus  Pyocyaneus.— Schimmel- 
buseh  states  that  the  bacillus  pyocyaneus  forms,  in  addition  to  the  green  or 
blue  colouring  matter,  brown  and  a  whole  series  of  colour- 
ing matters  ranging  all  the  way  from  brown  to  green.  ^  *■«  .,,»f4vv_- 
The  jjroduction  of  the  colouring  depends  upon  the  presence     s»  ^  $'    ''4,r;5%-5' 
of  sufficient  air,  proper  nutritive  media,  and  u])on  the  struc-      ' '    '^r",  '';r  ''»^" 
ture  of  the  bacilli.     The  latter  may  assume  diiferent  forms        .ft  ''^^V^'^ "''> 
in  different  nutritive  media,  and  may  even  be  unable  to            '•'^^^•■'^il^U  ' 
lose  their  property  of  producing  colouring  matters  under 
natural  or  artificial  conditions.                                                       ^'pyo|ene7^-tttidus 

Red  Pus. — There  is  occasionally  observed  a  red  cinna-  (Passet).  x^oo. 
bar-coloured  pus.  Ferchmin  found  that  the  causation  of 
this  red  jms  was  to  be  asci'ibed  to  a  special  form  of  bacillus  with  evenly 
rounded  ends,  which  could  be  cultivated  best  at  a  temperature  of  36°  to  37° 
C.  in  various  nutritive  media — agar-agar,  gelatine,  blood  serum,  potatoes. 
The  red  colouring  matter  is  easily  soluble  in  alcohol,  and  is  insoluble  in 
water,  ether,  and  chloroform.  In  man,  the  red  colour  of  the  pus  has  nothing 
to  do  with  the  reparative  process  in  a  wound.  In  i-abbits  especially  the  ba- 
cillus has  pathogenic  properties. 

Other  Pus  Microbes. — Amongst  the  other  pus  microbes  mention  should  be 
made  of  the  micrococcus  pyogenes  tenuis,  the  bacillus  pyogenes  fcetidus  Pas- 
set  (Fig.  259).  and  the  staphylococcus  cereus,  albus.  and  flavus.  These  bac- 
teria are  of  subordinate  importance  as  regards  man.  Eecently  the  bacillus 
pyogenes  foetidus  has  been  carefully  studied  by  Burci.  He  proved  that  it 
possessed  not  only  pyogenic  but  even  septic  properties  for  rabbits  and  mice. 
Neumann  and  Haegler  maintain  that  the  micrococcus  pyogenes  tenuis  is 
identical  with  the  pneumococcus  of  Frankel  and  Weichselbaum. 

Pneumococci  and  Typhoid  Bacilli  as  Excitants  of  Suppuration. — There  are 
still  other  micro-organisms  which  excite  suppuration.  It  is  occasionally  pro- 
duced by  pneumococci  (Schwartz,  Malgaigne)  in  the  form  of  secondary  sup- 
puration in  joints  during  pneumonia,  and  similar  phenomena,  due  to  the 
tj^phoid  bacillus,  may  occur  during  typhoid  fever,  etc.  The  suppurative  pro- 
cesses occurring  in  the  course  of  the  acute  infectious  diseases — for  example, 
in  diphtheria — are  due  to  the  presence  of  pus  cocci.     The  micrococcus  which 


326  INFLAMMATION  AND   INJURIES. 

causes  suppurative  inflammation  of  tlie  urethra,  tlie  vagina,  etc. — in  other 
words,  the  gonococcus  Neisser — is  discussed  in  the  Special  Surgery. 

Chi'onic  abscesses,  apart  from  those  due  to  syphilis,  glanders,  and  actino- 
mycosis, are  for  the  most  part  tubercular,  and  are  caused  by  a  characteristic 
bacillus  fKoch). 

Clinical  Forms  of  Inflammation  and  Suppuration  as  we  meet  them  in 
Surgery. — Clinically,  inflammation  and  suppuration  may  exist  in  various 
forms,  either  as  an  ordinary  superficial  suppuration  limited  to  the 
wound,  or  the  inflammation  may  extend  to  the  parts  in  the  neighbour- 
hood of  the  injury  and  result  in  a  cellulitis.  This  inflammation  may 
lead  to  more  or  less  circumscribed  suppuration  and  aVjscess,  or  to  dif- 
fuse and  often  rapidly  spreading  inflammatory  and  suppurative  pro- 
cesses. The  worst  form  of  spreading  inflammation  and  suppuration  is 
the  diffuse,  foul-smelling  inflammation  of  the  cellular  tissue,  to  which 
is  given  the  name  of  septic  phlegmon.  Inflammation  of  the  lymph 
vessels  is  called  lymphangitis.  Inflammations  of  the  vessels,  especially 
the  veins  (phlebitis^,  are  very  important,  particularly  as  regards  their 
dangerous  sequelae,  due  to  the  so-called  emboli.  The  spreading  inflam- 
mation which  involves  the  skin  and  subcutaneous  cellular  tissue,  the  so- 
called  erysipelas,  is  caused  by  an  inflammation  of  the  smaller  lymph  chan- 
nels, due  to  the  streptococcus  pyogenes.  The  gangrenous  breaking  down 
of  a  granulating  wound  is  called  hospital  gangrene,  or  wound  diphtheria. 
Accompanying  the  inflammation  and  suppuration  caused  by  micro-or- 
ganisms, there  is  more  or  less  fever,  due  to  secondary  infection  cr 
poisoning  of  the  lymph  and  blood  by  the  bacteria  and  the  products  of 
their  metabolism.  This  may  flnally  terminate  in  a  fatal  general  sys- 
temic poisoning,  which  we  shall  learn  about  more  particularly  under 
the  heading  of  Pyaemia  and  Septicaemia. 

We  shall  first  discuss  acute  inflammation  of  the  lymph  vessels 
(lymphangitis)  and  lymph  glands  (lymphadenitis). 

§  68.  Lymphangitis,  Lymphadenitis.  Acute  Inflammation  of  the 
Lymph  Vessels — Lymjjhangitis. — Acute  lymphangitis  is  characterised 
partly  by  a  change  in  the  lymph  and  walls  of  the  lymph  vessels,  and 
partly  by  a  perilymphangitis — i.  e.,  an  inflamtnation  of  the  connective 
tissue  surrounding  the  lymph  vessels.  The  starting-point  of  a  lym- 
phangitis is  usually  some  focus  of  infection  ;  in  other  words,  it  is  par- 
ticularly apt  to  originate  from  an  infected  wound.  The  interruption 
of  continuity  in  the  skin  is  frequently  most  insignificant.  The  inflam- 
matory irritant,  the  bacteria — and  these  are  generally  pus  cocci — are 
taken  up  by  the  lymph  vessels,  and  then  they  spread  into  the  larger 
lymph  channels,  and  wherever  the  bacteria  become  lodged  they  give 
rise  to  inflammation  or  thrombosis.     As  a  result  of  the  inflammation, 


§68.]  LYMPHANGITIS,   LYMPIIADENITLS.  307 

the  walls  of  the  lyiu])!!  vessels  undergo  a  change,  the  eiidntheliuni  may 
perish,  and  tlie  entire  wall  may  necrose,  suppurate,  etc.  The  lymphan- 
gitis may  terminate  in  either  a  restitutio  ad  integnnn^  with  absorption 
of  the  exudate  and  regeneration  of  the  destroyed  endothelium,  or  in 
abscess  formation  and  necrosis  of  the  walls  of  the  lymph  vessels  and 
surrounding  parts.  Chronic  inflammation  of  the  lympli  vessels  leads 
to  hyperplasia  of  the  connective  tissue,  with  induration  of  the  lymph 
vessels  and  the  tissue  surrounding  them. 

Histological  and  Experimental  Investigations  upon  the  Movement  of  the 
Lymph  during  Inflammation.— The  lynii;hatic  system  plays  both  a  passive 
and  an  active  part  in  iufiammatioii.  As  long  as  the  lymphatic  vessels  remain 
free  from  the  inflammatory  process,  they  carry  off  the  products  of  the  in- 
flammation, the  emigrated  leucocytes,  and  red  blood-corpuscles,  and  the  in- 
flammatory process  may  resolve  without  going  on  to  the  formation  of  an 
abscess.  An  abscess  is  particularly  apt  to  develop  when  the  walls  of  the 
blood-  and  lymph-vessels  become  affected  to  a  marked  degree  by  the  inflam- 
matory agent,  causing  a  retardation  of  the  lymph  current  and  insufficient 
removal  of  the  inflammatory  products.  The  slowing  of  the  lymph  current 
n)ay  eventually  become  a  complete  stasis,  with  emigration  of  the  leucocytes 
from  the  lymph  channels  and  a  corresponding  infiltration  of  the  tissues,  re- 
sulting in  abscess  or  gangrene  of  the  affected  parts.  The  changes  which 
occur  in  lymph-vessels  during  inflammation  are  the  same  as  those  that  occur 
in  the  blood-vessels. 

Clinical  Course  of  Acute  Lymphangitis  and  Lymphadenitis. — Acute 
lymphangitis  presents  the  following  clinical  picture :  After  the  reception 
of  a  wound  which  is  not  treated  aseptically,  possibly  a  superficial  abra- 
sion of  the  skin  on  the  fingers,  the  patient  complains  of  pain  in  liis 
entire  arm,  particularly  when  it  is  mov^ed.  AVhen  the  patient  is  care- 
fully examined  there  will  usually  be  found  a  painful  swelling  of  the 
epitrochlear  and  axillary  glands,  and  from  the  still  visible  wound,  or 
from  the  site  where  it  existed,  there  will  be  seen  red  stripes  leading  up 
to  the  axilla.  There  M-ill  ordinarily  be  fever  at  the  same  time.  The 
subsequent  course  of  the  disease  vai-ies.  There  either  occurs,  when 
proper  treatment  is  adopted  (rest,  elevated  position,  ice),  a  complete 
restitutio  ad  integrum,  or  there  is  a  continuation  of  the  fever,  with  an 
increase  of  the  local  inflammatory  symptoms  leading  to  suppuration, 
generally  in  the  form  of  circumscribed  abscesses  in  the  lymphatic 
glands  of  the  axilla  and  its  neighbourhood.  If  the  inflammation  in- 
volves the  more  deeply  lying  lymph  channels,  there  will  be  none  of 
the  above-mentioned  red  stripes  in  the  skin.  Acute  inflammation  may 
then  suddenly  develop  in  the  corresponding  lymphatic  glands,  which 
may  either  entirely  resolve  or  go  on  to  the  formation  of  an  abscess. 
Any  lymphangitis  is  capable  of  giving  rise  to  extensive  inflammation 


328  INFLAMMATION   AND   INJURIES. 

and  suppuration,  to  cellulitis,  erysipelas,  suppurative  periostitis,  gener- 
ally accompanied  bj  superiicial  necrosis  of  tlie  neighbouring  bone; 
also  to  general  systemic  infection,  pyaemia,  or  septicaemia,  terminating 
in  death.  All  these  possibilities  depend  upon  the  nature  of  the  poison 
which  is  absorbed,  or  upon  the  virulence  of  the  bacteria.  Occasionally 
a  severe  phlegmon  (§  TO),  or  a  general  systemic  poisoning — particu- 
larly pyaemia — makes  its  appearance  at  a  rather  late  period,  long  after 
the  Ivmphangitis  has  entirely  disappeared.  In  such  cases  the  bacteria, 
which  were  first  admitted  through  an  interruption  of  the  continuity  of 
the  skin,  lie  dormant  in  a  lymph  gland,  and  after  the  lapse  of  a  cer- 
tain length  of  time,  either  spontaneously  or  as  the  result  of  some  cause 
which  gives  rise  to  inflammation  (a  blow,  violent  muscular  movements, 
etc.),  they  may  suddenly  excite  dangerous  suppuration,  and  even  cause 
death  from  pyaemia  or  general  septic  poisoning  of  the  whole  system. 
The  study  of  the  clinical  course  of  lymphangitis,  caused  by  bacterial 
infection,  teaches  us  very  plainly  the  necessity  of  treating  with  anti- 
septic principles  even  the  most  insignificant  wound  on  the  surface  of 
the  body. 

The  Treatment  of  Acute  Lymphangitis  and  Lymphadenitis. — The  treat- 
ment of  acute  lymphangitis  and  lymphadenitis  in  fresh  cases  consists  in 
placing  the  aiiected  portion  of  the  body  in  a  proper  (elevated)  position 
and  giving  it  complete  rest.  For  lymphangitis  of  the  hand  the  arm 
should  be  fixed  in  the  vertical  position,  upon  Yolkmann's  suspension 
splint,  for  instance,  which  is  very  serviceable  for  this  purpose  (Tig.  177, 
pao-e  207) ;  the  circulation  is  thus  regulated,  the  afferent  arterial  current 
is  checked,  while  the  efferent  current  in  the  veins  and  lymphatics  is 
made  to  flow  off  more  readily,  and  the  inflammatory  swelling  goes 
down,  usually  very  rapidly.  Ice  should  be  applied  in  combination  with 
the  elevated  position,  or,  if  cold  is  not  well  borne,  moist  applications 
covered  over  with  rubber  tissue  are  excellent.  In  addition,  grey  mer- 
curial ointment,  very  gently  rubbed  in,  serves  a  useful  purpose.  The 
course  of  tlie  disease  must  be  carefully  watched  for  the  appearance  of 
any  localised  redness  and  swelling  indicating  suppuration.  AVhenever 
suppuration  can  be  demonstrated  by  fluctuation,  the  pus  should  be  let 
out  by  incision  at  the  earliest  possible  moment.  Occasionally  there  will 
be  noticed  a  great  tendency  to  recurrence,  especially  after  infection  by 
cadaver  poisoning  (^  7<i),  and  this  recurring  lymphangitis  requires  the 
most  careful  treatment.  In  such  cases  the  warm  baths  recommended  by 
Billroth  and  others  are  exceedingly  useful.  But  search  should  always 
be  carefully  made  for  the  possible  presence  of  some  focus  of  infection 
— some  small  wound,  ulcer,  pustule,  etc. — and  this,  when  found,  should 
be  treated  upon  antiseptic  principles. 


j5  6!).]  AUTKKITLS   AND    rilLEIilTIS.  329 

^  00.  Arteritis  and  Phlebitis.  Infaiumai'ion  of  the  WalU  of  the 
Jjlood-irfi,sr/s  {Ar/<?-t'/is,  J',  rinrti'rltls,  Phlehifls,  PeriphUhitts). — We 
referred  to  inflaiiiination  dt'  tlie  walls  of  the  vessels  in  the  chapters  on 
inriatnniation  (§  r)())  and  the  rej)air  of  wounds  (§  01).  "\Ve  saw  tliat  in 
every  intianunation  there  occurred  an  alteration  in  the  walls  of  the  ves- 
sels, and  tliat  in  every  injury  to  a  vessel  and  in  the  organisation  of  the 
thrombus  an  inflammation  took  ])Jace  for  tlie  purpose  of  forming  a 
cicatrix  in  the  vessel.  Ever}'  reparative  process  wliich  takes  ])lace  in 
a  wound,  even  though  aseptic  in  its  nature,  is  an  inflammatory  change  ; 
hut  the  aseptic  repair  of  the  injured  vessels  in  a  wound  and  tlie  organ- 
isation of  the  thrombi  into  vascular  connective  tissue  take  place  with- 
out any  disturbance.  When  an  injury,  liowever,  becomes  infected  by 
bacteria,  the  inflammation  which  then  develops  in  the  walls  of  the 
vessels  becomes  a  matter  of  great  importance. 

We  shall  concern  ourselves  here  principally  with  the  inflammation 
of  the  walls  of  the  vessels  which  results  in  suppuration — acute  suppura- 
tive arteritis  and  phlebitis.  Both  of  these  inflammatory  processes  are 
very  apt  to  be  observed  in  conjunction  with  a  su])])urating  woiind  or 
ulcer,  and  are  caused  by  micro-organisms,  particularly  those  micrococci 
which  excite  suppuration  (staphylococcus,  streptococcus,  etc.). 

The  suppurative  necrotic  arteritis  may  be  secondary  to  already  ex- 
isting disease  of  the  surrounding  tissues.  In  such  cases  the  inflamma- 
tion first  attacks  the  adventitia,  and  then  extends  to  the  inner  coats  of 
the  artery.  If  the  artery  contains  a  thrombus,  as  is  the  case  after  liga- 
tion, the  thrombus  may,  from  the  influence  of  the  bacteria  which  have 
entered  it,  undergo  a  suppurative  breaking  down  (thrombo-arteritis 
purulenta),  and  as  a  resnlt  of  the  sloughing  of  the  arterial  wall  a 
hemorrhage  may  result  which  can  endanger  the  life  of  the  patient. 
In  other  cases  the  suppurative  thrombo-arteritis  is  developed  by  em- 
boli, which  carry  the  infectious  material  from  some  focus  of  infection 
into  the  blood-vessels,  and,  finding  lodgment  at  some  point,  produce 
there  suppurative  changes  (metastatic  abscesses). 

In  suppurative  inflammation  of  the  veins  (phlebitis)  practically  the 
same  phenomena  are  observed.  It  is  caused  either  by  the  direct  en- 
trance of  bacteria  into  the  blood-vessels  or  by  the  extension  to  the  latter 
of  an  infectious  inflamination  in  the  surrounding  parts ;  for  instance, 
an  acute  suppurative  inflammation  of  the  cellular  tissue  may  extend 
and  involve  the  walls  of  a  vein.  The  inflammation  in  the  wall  of  a 
vein,  particularly  the  alteration  which  it  produces  in  the  intima,  the 
endothelium,  gives  rise  to  the  formation  of  a  thrombus  and  thrombo- 
phlebitis ;  or  else  this  order  is  reversed,  and  the  thrombus  forms  before 
there  is  an  inflammation  of  the  walls  of  the  vein.    In  the  veins  thrombi 


330 


INFLAMMATION  AND  INJURIES. 


Fig.  260.— Throm- 
bus in  the  valve 
of  a  vein  (sche- 
matic). 


Fig.  261.— Purulent 
thrombus  of  a 
vein  (schemat- 
ic). 


are  particularly  liable  to  develop  in  the  region  of  the  valves  (Fig.  260), 
as  the  blood  current  flows  more  slowly  at  these  points  than  at  others, 

and  the  micro-organisms  can  thus 
more  easily  find  lodgment  (Fig. 
260).  If  in  a  suppurative  throm- 
bophlebitis the  suppurating  masses 
containing  micrococci  are  swept 
off  in  the  blood  current  to  other 
parts  of  the  body,  wherever  they 
are  deposited  they  form  the  above- 
mentioned  metastatic  abscesses  re- 
sulting in  pyaemia  (§  Y5).  Buday 
maintains  that  the  lodgment  of 
emboli  made  up  of  large  particles 
of  tissue  or  masses  of  cocci  is  by 
no  means  necessary  for  the  pro- 
duction of  metastatic  suppuration; 
the  micro-organisms  circulating  in  the  blood  may  become  lodged  in 
the  endothelium  of  the  vessels,  and,  growing  very  rapidly,  break  through 
their  walls  and  give  rise  to  phlebitis,  thrombosis,  and  secondary  phleg- 
monous processes.  From  what  has  just  been  said,  it  follows  that  every 
infection  of  the  blood  by  micro-organisms,  every  suppurative  inflamma- 
tion, as  soon  as  it  extends  to  the  walls  of  a  vessel  and  reaches  its  lumen, 
is  an  exceedingly  grave  event  on  account  of  the  spreading  of  the  pus, 
or  rather  the  bacteria,  through  the  circulation. 

Other  inflammatory  conditions,  affecting  the  walls  of  the  vessels, 
which  concern  the  surgeon,  are  the  acute  inflammations  which  are 
particularly  liable  to  occur  in  the  intima  of  the  aorta  and  the  other 
arteries  in  pysemic  and  septic  infections  of  the  general  system,  and 
which  are  due  to  the  bacteria  or  the  products  of  their  metabolism 
circulating  in  the  blood.  Anatomically,  these  inflammations  are  char- 
acterised by  the  formation  of  groups  of  small  cells  in  the  intima  and 
the  other  coats  of  the  arteries,  and  by  a  fibrinous  exudation  into 
the  intima,  the  latter  being  sometimes  covered  by  a  tough  layer  of 
fibrin. 

It  is  important  for  the  surgeon  to  bear  in  mind  that  the  acute  in- 
flammations occurring  in  the  walls  of  the  vessels  in  conjunction  with 
injuries  to  the  soft  parts  are,  after  all,  only  partial  manifestations  of 
other  local  and  general  bacterial  infections,  such  as  a  circumscribed 
or  spreading  cellulitis,  erysipelas,  pyaemia,  or  septicaemia.  "We  shall 
therefore  abstain  from  going  into  the  diagnosis  and  treatment  of  in- 
flammation of  the  walls  of  the  vessels  separately  at  present,  as  this 


g  70. J  CELLULITIS.  331 

subject  Mill  1)0  brouglit  up  a^iiiu  in  conuection  with  the  diagnosis 
and  treatniont  of  the  inHamuiations  or  infections  of  the  nurrounding 
parts. 

The  phlebitis  and  tht!  periphlebitis  which  sometimes  occur  in  u  more 
or  less  isolated  form  like  a  lymphangitis,  and  often  originate  from  some 
insignificant  injury,  are  diagnosed  and  treated  brieHy  as  follows :  The 
8ube*itaneous  veins  feel  like  cords  on  account  of  the  inflammatory 
thickening  of  their  walls  and  the  thrombosis  which  takes  place  in  their 
interior.  The  process  is  essentially  a  periphlebitis  with  inflammatory 
infiltration  of  the  sheaths  of  the  vessels,  and  the  veins  are  not  always 
thrombosed.  If,  however,  thrombi  do  exist  in  the  veins,  there  is  usu- 
ally a  corresponding  cedematous  swelling  from  the  disturbance  in  the 
circulation.  The  treatment,  particularly  when  the  disease  occurs  in 
the  lower  extremity — and  it  soinetimes  occurs  spontaneously  in  individ- 
uals with  varicose  dilatation  of  the  veins — consists  in  placing  the  ex- 
tremity in  a  properly  elevated  position,  enveloping  it  in  a  moist  dress- 
ing covered  with  rubber  tissue,  and,  in  addition,  rubbing  in  mercurial 
ointment.  This  rubbing  in  or,  more  correctly,  inunction  of  mercurial 
ointment  for  phlebitis  must  be  done  with  the  greatest  caution  and  by 
gentle  strokes  of  the  hand,  so  as  not  to  loosen  any  thrombi  and  have 
them  carried  off  into  the  general  circulation,  as  sudden  death  may 
result  from  cerebral  embolism,  or  from  the  lodgment  of  an  embolus  in 
the  pulmonary  artery.  By  this  treatment  the  local  disease  and  the 
fever,  when  the  latter  exists,  are  caused  to  disappear ;  the  cord-like 
veins  becoming  softer  after  the  lapse  of  about  six  to  eight  days,  and 
finally  assuming,  by  degrees,  a  perfectly  normal  character.  In  such 
cases  the  phlebitis  or  the  periphlebitis,  whether  there  has  been  a 
thrombus  formation  or  not,  resolves  to  a  complete  restitutio  ad  inte- 
grum. If  an  abscess  develops,  the  pus  should  be  let  out  as  soon  as 
possible  by  an  incision.  A  permanent  occlusion  of  the  vessel  some- 
times follows  the  organisation  of  a  thrombus  in  a  vein ;  this  is  particu- 
larly apt  to  happen  in  varicose  veins  of  the  leg.  The  so-called  phlebo- 
liths  (vein  stones)  result  from  calcification  of  venous  thrombi.  The 
manner  in  which  thrombi  develop,  and  the  changes  w'hich  occur  in 
them,  have  been  described  on  ]iages  290-294. 

§  70.  Cellulitis.— By  cellulitis  is  meant  an  inflammation  of  the  soft 
parts,  which  has  a  tendency  to  go  on  to  suppuration,  and  is  particu- 
larly liable  to  be  located  in  the  subcutaneous  cellular  tissue,  or  more 
deeply  in  the  intermuscular  cellular  tissue,  or  beneath  fascia,  in  the 
sheaths  of  tendons,  in  the  periosteum,  etc.  We  distinguish  clinically 
two  principal  classes — ^the  circumscribed  and  the  diftuse.  The  former 
remains  more  or  less  limited  to  the  neiirhbourhood  of  the  original  start- 


332 


INFLAMMATION   AND   INJURIES. 


ing-point  of  the  inflammation,  while  the  latter  has  a  marked  tendency 
to  spread  and  become  a  progressive  process,  the  worst  form  of  which 
is  the  very  acute  septic  phlegmon ;  the  inflammation  sometimes  mani- 
fests a  tendency  to  spread  with  incredible  rapidity. 

It  is  not  always  plainly  visible  open  wounds,  or  large  recent  inju- 
ries, which  give  rise  to  the  cellulitis.  Often  enough  it  is  an  insignifi- 
cant, perhaps  already  healed,  abrasion  of  the  epidermis  near  the  «ail, 
such  as  a  scratch  or  a  needle  prick,  which  forms  the  starting-point  for 
a  spreading  inflammation.  Not  infrequently,  the  cellulitis  develops  at 
some  spot  widely  removed  from  the  point  of  inoculation,  from  which 
the  bacteria  have  been  carried  off  in  the  lymph  channels,  finally  lodg- 
ing in  some  suitable  locality,  a  lymph  gland,  for  instance,  where  they 
grow  and  develop.  The  cellulitis  which  used  to  be  called  spontaneous 
in  its  origin  does  not  exist.     There  is  always  an  infection  by  bacteria, 


\| 


Fio.  262. — Streptococcus  of  progressive  tissue  necro- 
sis in  mice  (Koch);  a,  cells  of  the  cartilage  in  the 
ear ;  J,  streptococci,     x  700. 


Fio.  20.3. — Intcrmus'>ular  phlegmon  of 
the  forearm  ;  streptococcus  pyogenes 
between  the  muscle  bundles ;  stained 
with  gentian  violet  (after  Gram). 
X  250. 


or  by  the  products  of  their  metabolism  (staphylococcus  pyogenes  au- 
reus, streptococcus  pyogenes,  the  bacillus  of  malignant  oedema,  less 
often  other  pus  cocci). 

The  Micro-organisms  found  in  the  Different  Forms  of  Cellulitis ;  Pus  Cocci. 
— Cellulitis  is  most  frequently  excited  by  the  staphylococcus  pyogenes  aureus 
and  the  streptococcus  pyogenes,  though  there  are  sometimes  found,  other  pus 
cocci,  such  as  the  staphylococcus  pyogenes  albus,  the  micrococcus  pyogenes 
tenuis,  the  bacillus  pyogenes  foetidus,  the  bacillus  pyocyaneus,  etc.     Occa- 


^  '0.] 


CELLUMTIS. 


333 


sionally  there  will  be  found  only  a  relatively  small  number  of  cocci  in  the 
inllainnialory  collections,  the  tissues  being  caused  to  necrose  extensively  by 
the  chemical  products  of  the  bacterial  metabolism  (Fi{?.  202).  Again,  in  other 
cases,  the  cocci  will  be  present  in  vast  numbers  (Fig.  203).  The  cellulitis 
excited  by  the  streptococcus  is  characterised  generally  by  a  marked  tendency 
to  si)ivad  witli  great  rapidity. 

Bacillus  of  Malignant  (Edema.— The  worst  forms  of  cellulitis,  the  so-called 
acute  malignant  u?dema,  progressive  gangrenous  emphysema  (PirogofF's  acute 
purulent  crdema,  Maisonneuve's  gangrene  fondroyante),  are  excited  by  a 
specific  bacillus  first  identified  by  Robert  Koch.  These  little  rods  are  prob- 
ably identical  with  the  ribrioufi  septiques  found  by  Pasteur  in  septicaemia. 
In  man,  malignant  oedema  occurs,  for  instance,  in  conjunction  with  a  com- 
pound (open)  fracture  which  does  not  receive  aseptic  treatment,  or  from 
any  wound  not  aseptically  treated.  It  is  characterised  by  an  extensive  em- 
physema (evolution  of  gas)  and  by  decomposition  of  the  soft  parts,  and 
it  almost  always  terminates  in  death  after  the  lapse  of  a  few  days.  The 
bacillus  of  malignant  oedema  is  very  apt  to  be  found  in  the  superficial  strata 
of  garden  earth,  in  the  dvist  collectiug  in  the  cracks  of  a  floor,  in  all  sorts 
of  decomposing  matter,  in  dirty  water,  etc.     It  is  more  slender  than  the 


Fig.  264. — A,  bacillus  of  malignant  oedema.     H,  spore-formation. 

anthrax  bacillus,  being  3'0  to  3*5  /i  long  and  about  10  fi  broad  ;  it  has 
pointed  or  rounded  ends,  and  often  forms  long  filaments  which  may  have 
different  crooks  or  bends  (Fig.  264,  A).  These  bacilli  are  capable  of  very 
active  movement,  and  possess  cilia  on  the  sides,  which  can  be  demonstrated 
by  means  of  Loffler's  method  of  staining.  Spores  make  their  appearance  in 
the  cultures  by  the  end  of  the  first  day,  forming  best  at  a  temperature  of 
37°  C.  (98'6°  F.),  (body  temperature),  in  which  they  grow  very  rapidly,  more 
slowly  at  ordinary  room  temperatures.  When  developing  spores,  the  bacilli 
enlarge  at  one  end  or  in  the  middle  (Fig.  264,  B).  The  oedema  bacilli  are 
strictly  anaerobic,  and  can  only  be  cultivated  in  an  atmosphere  free  from 
oxygen.  On  gelatine  plates  the  colonies  form  small  shining  knobs  contain- 
ing fluid,  and  the  gelatine  is  liquefied.  On  agar  plates  they  form  rough, 
matted  clusters  with  an  ill-defined  border.  Puncture  cultiu-es  in  agar-agar, 
to  which  should  be  added  one  to  two  per  cent,  of  grape  sugar,  develop  in  diffuse 
cloudy  groups  (Fig.  265).     Cultures  in  blood  serum  show  a  homogeneous 


334 


INFLAMMATION  AND   INJURIES. 


cloudiness  in  the  line  of  tlie  puncture.  In  the  interior  of  a  boiled  potato 
the  bacilli  can  be  made  to  grow  at  a  temperature  of  38°  C.  (1004°  F.),  and  after 
several  days  the  potato  will  be  found  riddled  with  a  network  of  bacilli.  The 
bacilli  can  be  stained  by  all  the  aniline  dyes,  and  will  then  frequently  present 
a  granular  appearance.  Gram's  double  stain  cannot  be  used.  If  01  to  0"3 
cubic  centimetres  of  a  bouillon  culture  is  injected  into  tbe  subcutaneous  tissue 
of  mice  and  guinea-pigs,  the  animal  thus  inoculated  will  die  in  eight  to 
fifteen  hours.  Upon  post-mortem  examination  there  will  be  found  starting 
fi'om  the  point  of  inoculation  an  extensive  subcutaneous  oede- 
ma, the  fluid  of  which  it  consists  being  of  a  reddish  colour 
and  full  of  bacilli,  with  bubbles  of  gas  scattered  here  and 
there.  Tbe  bacilli  will  be  found  located  principally  in  tbe 
serous  cavities  and  in  the  fluids  contained  in  the  different  or- 
gans. Guinea-pigs  inoculated  with  the  peritoneal  fluid  taken 
from  such  an  animal  will  die  very  quickly.  The  bacilli  can 
only  be  demonstrated  in  tbe  blood  several  days  after  death. 
If  bouillon  cultures  are  kept  for  ten  minutes  at  a  temperature 
of  115°  C.  (239°  F.),  or  if  they  are  filtered  first  through  porce- 
lain, and  then  about  100  cubic  centimetres  of  the  fluid  ren- 
dered germ-free  in  eitber  way  are  injected  at  three  successive 
periods  into  the  peritoneal  cavity  of  a  guinea-pig,  the  animal 
will  be  rendered  immune  from  subsequent  inoculations  with 
the  bacilli  themselves.  In  other  words,  bj  injecting  the  prod- 
ucts of  the  metabolism  of  the  bacilli,  the  animals  can  be  made 
unsusceptible  to  the  bacilli. 

Septic  Emphysema  due  to  the  Bacillus  Coll  Communis.— 
In  a  case  of  fatal  septic  emphysema  in  Gussenbauer's  clinic, 
Chiari  found  that  the  bacillus  coli  communis  was  the  cause  of 
the  disease.  Chiari  attempted  to  excite  a  disease  analogous  to 
the  "septic  emphysema  "in  man  with  its  gas  formation,  by 
injecting  these  bacilli  into  animals,  but  all  his  attempts  failed. 
He  could  not  bring  about  gas  formation,  though  he  made  in- 
travenous, intraperitoneal,  and  subcutaneous  injections.  The 
animals  died  from  septicaemia,  and  the  bacilli  taken  from  their 
dead  bodies  and  isolated  in  pure  cultures  evolved  gas  in  con- 
siderable quantities. 

Symptoms  of  a  Circumscribed  Cellulitis. — The  symp- 
toms of  a  more  or  less  circumscribed  celhilitis  vary  with 
the  latter's  situation ;  the  more  superficial  the  inflammation  is,  the 
plainer  are  the  manifestations  of  the  beginning  cellulitis.  In  a  superfi- 
cial cellulitis,  involving  the  skin  and  subcutaneous  cellular  tissue,  the 
aJBfected  skin  area  is  red  and  swollen,  it  feels  hot,  and  is  painful  upon 
pressure.  The  skin  is  tense  with  oedema  and  cannot  be  lifted  from  the 
underlying  parts.  The  infiltration  feels  hard  at  first,  but  subsequently, 
with  the  onset  of  suppuration,  it  becomes  soft  and  dongliy.  Resolu- 
tion of  the  inflammation  without  suppuration  is  a  very  rare  occurrence. 
When  the  transition  to  pus  has  taken  place,  when  an  abscess  is  present, 


Fio.  265.— Pure 
culture  of  the 
l)acilli  of  ina- 
lignant  oede- 
iiia.  Agar-in- 
digo  -  sodium 
sulphate. 


g  70.]  CELLULITIS.  335 

the  afiFected  area  fluctuates — i.  e.,  by  alternating  pressure  made  Avith 
both  index  finj^ers,  the  pus  is  caused  to  "  fluctuate  "  or  take  on  a  wave 
motion,  as  any  fluid  will  do  when  set  in  motion  in  a  cavity  with  yield- 
ing walls.  The  pus  either  forces  its  way  to  the  surface  through  the 
skin,  which  undergoes  a  gradual  thinning  process,  or  it  is  evacuated  by 
an  incision.  The  longer  the  suppuration  is  allowed  to  continue  before 
being  permitted  to  escape  externally  the  more  apt  is  the  pus  to  burrow 
or  extend  to  the  parts  in  the  neighbourhood  of  the  abscess.  In  this 
way  a  spreading  cellulitis  dangerous  to  life  may  originate  from  a  cir- 
cumscribed cellulitis  or  suppuration. 

If  a  circumscribed  cellulitis  is  deeply  situated  at  the  outset,  there 
is  but  little  change  in  the  skin,  and  neither  swelling  nor  redness  will  be 
present,  and  only  when  the  deep  process  draws  near  to  the  surface  of 
the  body  will  any  of  the  above-described  manifestations  of  its  presence 
be  revealed,  the  first  being  pain  on  pressure  and  oedema  of  the  skin. 

In  the  neighbourhood  of  the  circumscribed  cellulitis  there  will  be 
necrosis  of  the  skin,  and  particularly  of  the  fascia,  tendons,  tendon 
sheaths,  muscles,  and  bones,  in  proportion  to  the  amount  of  inflammatory 
infiltration  and  the  ensuing  suppurative  breaking  down.  This  death 
of  tissue  will  be  the  more  easily  prevented  or  limited  the  earlier  incisions 
are  made,  and  the  cavity  washed  out  with  antiseptic  solutions  of  bi- 
chloride of  mercury  (1  to  1,000-2,000)  or  of  carbolic  acid  (three  per 
cent.).  Every  cellulitis  which  is  not  recognised  early  in  its  course  may 
not  only  lead  to  extensive  suppuration,  with  a  proportionate  destruction 
of  tissue,  but  may  even  cause  the  death  of  the  patient  from  a  fatal  gen- 
eral systemic  infection — pysemia,  for  instance — if  the  inflammatory  ele- 
ments are  carried  off  and  spread  throughout  the  body  Ijy  the  blood- 
vessels. Under  such  conditions  inflammation  of  the  lymph  channels 
(lymphangitis)  and  inflammation  of  the  arteries  and  veins  (arteritis, 
phlebitis)  may  be  excited,  with  the  formation  of  suppurating  thrombi  in 
the  veins,  also  swellings  and  abscesses  of  the  lymph  glands,  and  meta- 
static abscesses  in  the  internal  organs,  etc.  Accompanying  every  cir- 
cumscribed cellulitis  there  will  be  fever,  the  intensity  of  which  will 
vary  according  to  the  virulence  of  the  poison. 

Whitlow  or  Paronychia. — Paronychia  or  whitlow  is,  for  the  most  part,  at 
the  outset  a  circumscribed  inflammation  of  the  subcutaneous  cellular  tissue 
of  a  finger,  particularly  on  its  palmar  aspect,  though  it  may  begin  in  the 
palm  of  the  hand.  Paronychia  may  appear  to  begin  spontaneously,  but 
usually  results  from  some  injury,  which  may  be  only  a  very  small 
abrasion  of  the  epidermis.  It  is  most  apt  to  occur  in  individuals  who  are  con- 
stantly receiving  superficial  injuries  of  the  skin  on  their  fingers,  or  in  those 
who,  like  physicians  and  anatomists,  frequently  handle  decomposing  sub- 
stances and  thus  infect  themselves.     The  inflammation  is  more  likely  to 


336  INFLAMMATION  AND  INJURIES. 

spread  into  the  deeper  parts  than  to  come  to  the  surface;  but  there  are  also 
superficial  forms  of  paronychia  which  spread  very  rapidly.  The  pain  is 
usually  very  severe,  as  great  pressure  is  exerted  upon  the  nerves  in  the  tense 
tissues.  Death  of  tissue  is  a  common  occurrence  as  a  result  of  the  closure  of 
the  capillaries  and  small  veins  and  arteries  by  pressure.  If  the  paronychia 
extends  to  the  tendon  sheath,  it  usually  spreads  rajiidly  on  account  of  the 
looseness  of  the  tissue.  From  a  neglected  paronychia  or  whitlow,  resulting 
in  a  spreading  cellulitis,  many  a  patient  has  suiiered  a  serious  loss  of  func- 
tion of  the  hand,  or  the  hand  itself,  or  the  forearm,  or  the  whole  arm,  while 
the  lives  of  some  patients  have  not  been  saved  even  by  an  amputation. 

Symptoms  of  the  Diffuse  Spreading  Cellulitis. — The  diffuse  spreading 
cellulitis,  formerly  called  diphtberitis  of  the  cellular  tissue,  is  usually 
very  acute  and  much  worse  than  the  circumsci-ibed  variety.  Like  the 
latter,  it  is  sometimes  caused  by  very  trifling  injuries,  such  as  a  needle 
prick,  or  by  a  wound  of  the  soft  parts  of  a  bone,  or  of  a  joint,  which 
is  not  brought  soon  enough  under  the  protection  of  an  antiseptic  treat- 
ment. The  local  manifestations  are  at  the  outset  the  same  as  those  of 
a  circumscribed  cellulitis.  In  many  instances  the  disease  begins  with 
a  severe  chill  and  a  proportionately  high  fever.  The  changes  in  the 
overlying  skin  may  at  flrst  be  very  slight,  and  in  fact  it  is  not  even 
reddened  in  the  very  dangerous  deep  forms  of  cellulitis  which  spread 
very  rapidly.  Just  these  cases  are  the  ones  so  often  unrecognised  by 
the  beginner.  The  process  spreads  quickly  in  the  deep  sul)fascial  cellu- 
lar tissue,  and  may  terminate  in  a  relatively  short  time  in  a  fatal  sys- 
temic infection.  But  in  a  spreading  diffuse  cellulitis,  the  skin  is  gen- 
erally involved,  and  has  a  dark  or  bluish-red  colour,  and  not  infrequently 
the  epidermis  is  elevated  by  blebs ;  there  is  also  an  inflammatory  in- 
filtration of  the  skin  wdiich  may  make  it  as  hard  as  a  board.  If  the 
cellulitis  is  deeply  situated,  the  skin  feels  more  doughy  and  cedematous. 
The  pain  is  very  marked  and  usually  there  is  a  high  fever.  ISTot  rarely 
the  course  of  the  disease  is  so  acute  that  even  after  the  expiration  of 
four  to  five  days  disarticulation  of  the  extremity  may  be  necessary,  or 
it  may  even  then  be  too  late  to  prevent  the  death  of  the  patient  from  the 
general  systemic  poisoning.  This  form  of  septic,  spreading  cellulitis  with 
high  fever,  extensive  gangrenous  destruction  of  tissue,  and  death  by 
general  systemic  poisoning,  has  a  very  unfavourable  prognosis,  and  has 
received  the  names  of  malignant  oedema,  progressive  gangrenous  em- 
physema, acute  purulent  oedema  (Pirogolf),  and  gangrene  fondroy ante 
(Maisonneuve).  These  dangerous  forms  of  septic  cellulitis  are  excited 
by  the  bacillus  pictured  in  Fig.  264. 

If  the  diffuse  inflammatory  infiltrate  in  the  subcutaneous  cellular 
tissue,  in  the  subfascial  and  intermuscular  tissue,  the  sheaths  of  the 
tendons,  and  in  the  periosteum,  is  changed  into  pus  and  softens,  the 


§  70.]  CELLULITIS.  337 

pain  decreases,  aiul  there  follows  an  extensive  necrosis  of  the  infiltrated 
tissues,  including  the  skin,  subcutaneous  cellular  tissue,  fascia,  muscles, 
tendons,  and  bone.  Large  sacs  are  formed  filled  with  pus,  the  skin 
is  lifted  from  the  underlying  parts,  and  joints  are  opened.  As  a  result 
of  the  decomposition  of  the  pus,  em])hysema,  or  the  formation  of  gas, 
takes  place,  and  this  may  be  so  marked  that  a  peculiar  crackling  can 
be  obtained  on  palpation,  and  a  more  or  less  tympanitic  resonance  will 
be  elicited  on  percussion.  If  the  diffuse  cellulitis  docs  not  carry  off  the 
patient  by  general  sepsis,  the  subsequent  course  of  the  disease  Is  often 
very  tedious,  consisting  in  the  gradual  sloughing  away  of  the  gangre- 
nous parts,  and  the  proportionate  formation  of  cicatricial  contractures 
in  the  skin,  tendons,  muscles,  joints,  etc.  The  patient  may  also  die  in 
this  stage  from  pyae-mia,  marasmus,  parenchymatous  degeneration  of 
the  internal  organs,  or  from  extension  of  the  inflammation  to  vital 
parts — for  example,  from  the  skull  to  the  meninges.  Death  may  also 
result  from  haemorrhage  following  suppurative  perforation  of  the  arte- 
ries or  large  veins,  etc. 

Prognosis  of  Cellulitis. — The  pt'ognosis  of  cellulitis  varies  greatly, 
depending  upon  the  situation  of  the  disease,  the  extent  of  the  inflam- 
mation, and  the  kind  of  bacteria  which  excites  the  process.  A  cellu- 
litis of  the  scalp,  for  instance,  is  a  serious  matter,  from  the  danger  of 
the  inflammation  spreading  to  the  cranial  cavity.  In  general,  the  super- 
ficial forms  of  cellulitis  are  not  dangerous,  while  the  deeper,  subfascial, 
spreading  forms,  by  causing  general  systemic  infection,  involve  the 
greater  risk  to  life  the  longer  they  remain  unrecognised.  The  worst 
forms  are  those  with  progressive  emphysema,  caused  by  infection  with 
the  bacillus  of  malignant  oedema ;  they  often  terminate  fatally  within 
a  few  days,  before  the  local  manifestations  of  the  process  become  plainly 
marked.  The  prognosis  of  the  others  may  be  inferred  from  what  has 
been  said  of  them. 

Treatment  of  a  Cellulitis. — The  treatment  of  every  cellulitis  is  prac- 
tically the  same,  whether  the  inflammation  is  circumscribed  or  spread- 
ing. Much  time  used  to  be  lost  by  the  employment  of  cataplasms  to 
obtain  resolution  of  the  inflammation.  The  knife  should  be  used  as 
soon  as  possible,  and  free  incisions  made  to  diminish  the  inflammatory 
tension  of  the  tissues  and  to  allow  the  pus  to  escape,  after  which  the 
entire  focus  of  the  inflammation  should  be  disinfected  by  one-tenth-per- 
cent, solutions  of  bichloride  of  mercury,  or  by  three-  to  five-per-cent. 
solutions  of  carbolic  acid.  We  do  not  wait  till  suppuration  and  break- 
ing down  of  the  tissues  have  taken  place,  but  we  immediately  make  an 
incision  into  the  region  where  there  is  the  most  pain  or  the  most  pro- 
nounced swelling  and  inflammatory  infiltration,  even  though  there  may 


338  INFLAMMATION  AND  INJUIRES. 

be  as  yet  no  pus  present.  If  early  incisions  are  thus  made  it  may  be 
possible  to  prevent  death  of  tissue  from  taking  place,  particularly  in 
the  tendon  sheaths,  bones,  etc.,  or  at  least  to  limit  the  amount  of  it,  and 
cases  treated  in  this  manner  will  heal  comparatively  the  most  rapidly. 
The  incisions  should  not  be  too  small ;  it  is  better  to  make  them  too 
free  rather  than  not  large  enough.  The  collection  of  pus  should  be 
laid  bare  throughout  its  whole  extent  by  long  incisions,  and  any  pockets 
tliat  may  be  present  opened  up.  If  the  cellulitis  is  deep,  the  incision 
should  be  carried  through  the  skin  and  fascia  wuth  the  knife,  and  then 
the  incision  should  be  deepened  with  a  blunt  instrument — a  closed 
dressing-forceps,  for  instance — till  finally  the  bone  is  reached.  In  an 
extensive  cellulitis  the  parts  which  appear  sound  must  be  examined  very 
carefully,  to  determine  whether  pus  may  not  have  burrowed  into  or 
beneath  them.  After  making  the  incisions  the  region  in  which  there 
have  been  large  collections  of  pus  should  be  washed  out  vigorously 
with  a  1  to  1,000  solution  of  bichloride  of  mercury,  or  three  to  five  per 
cent,  of  carbolic  acid.  The  incisions  should  be  so  placed  as  to  facilitate 
the  escape  of  tlie  pus,  which  is  then  provided  for  by  proper  drainage 
(§  31),  or  by  packing  with  iodoform  gauze,  sterilised  mull,  etc.  The 
best  dressing  for  a  circumscribed  cellulitis  is  one  which  is  antiseptic 
and  absorbent — for  example,  iodoform  gauze,  sterilised  mull  and  cotton, 
or  pads  of  moss,  jute,  etc.  Of  course,  the  dressings  should  not  exei't 
any  more  than  moderate  pressure,  to  prevent  pus  from  being  forced 
into  the  connective-tissue  spaces.  In  cellulitis  of  the  fingers,  I  prefer 
to  have  the  first  dressings  moist  rather  than  dry,  and  to  make  use  of 
frequent  antiseptic  baths,  and  then,  later,  to  use  as  dressings  ointments 
of  iodoform  and  boric  acid.  Poultices,  which  used  to  be  so  much  in 
vogue,  should  be  condemned.  Their  use  has  caused  much  harm.  To 
be  able  to  determine  whether  there  is  any  burrowing  or  retention  of 
pus,  the  dressings  must  at  first  1)0  frequently  changed,  possibly  every 
day,  or  every  second  or  third  day;  and  not  until  the  wound  begins  to 
granulate  and  suppuration  ceases  can  the  dressings  be  left  undisturbed 
for  a  longer  period.  If  the  suppuration  has  been  extensive,  secondary 
sutures  may  be  of  service  in  hastening  the  repair  after  the  packing  has 
been  removed. 

In  diffuse  cellulitis,  with  extensive  destruction  of  tissue,  long  in- 
cisions, followed  by  packing  the  wounds,  are  particularly  valuable,  and 
this  may  be  subsequently  supplemented  with  advantage  by  antiseptic 
washings  or  permanent  irrigation  (pages  179,  180).  After  the  gangre- 
nous tissues  are  cast  o£E  and  the  granulating  stage  has  begun,  a  return 
may  be  made  to  antiseptic  protective  dressings  of  iodoform,  oxide  of 
zinc,  etc.     To  shorten  the  time  required  by  a  large  granulating  wound 


§71.]  ERYSIPELAS.  339 

to  become  covered  with  skin,  Thiersch's  skin  grafts  are  very  useful 
(see  §  42).  In  the  treatment  of  every  celluHtis,  it  is  exceedhigly  im- 
portant to  secure  for  the  intiamed  part  a  proper  ])osition  upon  splints 
(§  53),  or  in  a  uiitella  (Fig.  155),  etc.  Elevation  of  an  intlumed  lower 
extremity,  or  vertical  suspension  of  an  inflamed  hand,  has  an  excellent 
elfect,  and  sometimes  works  wonders.  In  the  worst  cases  of  septic 
cellulitis,  amputation  or  disarticulation  of  the  affected  extremity  will 
sometimes  be  found  necessary  in  order  to  save  the  life  of  the  patient. 
Unfortunately,  the  operation  is  sometimes  performed  too  late,  when 
general  sepsis  is  already  present. 

The  after-treatment  of  the  sequelae  of  cellulitis,  the  cicatricial  con- 
tractures, necrosis  of  bone,  etc.,  is  conducted  on  the  lines  laid  down 
for  these  conditions  in  another  chapter  (Contractures,  Xecrosis  of  Bones). 

Phlegmasia  Alba  Dolens  is  an  inflammation  of  the  leg,  rarely  of  both 

legs,  running  u  slow  course,  with  oedema  and  i^ain.  principally  due  to  venous 
tjirombosis  and  oecuiTing  mostly  in  lying-in  women  and  in  cachectic  pa- 
tients (tuberculosis,  carcinoma,  etc.).  The  pjilegmasia  alba  dolens  of  jiuer- 
peral  women  is  usuallj^  caused  by  the  extension  of  an  infectious  inflamma- 
tion of  the  pelvic  connective  tissue  (parametritis),  which  ordinarily  takes 
glace  in  the  second  week  after  confinement.  It  terminates  either  in  absorp- 
tion of  the  inflammatory  infiltrate,  or  in  suppuration  or  gangrene,  and 
rarely  in  deatb,  which  is  then  apt  to  be  due  to  embolism  or  sepsis.  The 
phlegmasia  alba  dolens  of  cachexia  is  mainly  the  result  of  venous  stasis, 
caused  by  defective  cardiac  and  pulmonary  activity.  It  rarely  goes  on  to 
suppuration.  4 

§  71.  Erysipelas. — By  erysipelas  (from  ipvdpo^i,  red,  and  iriWa, 
skin)  is  meant  a  spreading  inflammation  of  the  external  cutaneous 
covering  of  the  body^  or  rather  of  its  smaller  lymph  channels,  and 
of  those  of  the  subcutaneous  cellular  layer,  cajised  by  bacteria  (strep- 
tococcus). It  is  a  specific  dermatitis,  characterised  (1)  by  a  more  or 
less  rapid,  for  the  most  part,  continuous  extension  alqng^the  surface, 
less  often  into  the  deeper  parts;  (2)  by  a  toxic  diseased  state  of  the 
general  system  (intoxication  fever)  going  hand  in  hand  with  the  local 
inflammatory  disease;  and  (3)  generally  by  a,  com])\ete  restitutio  ad 
integriiin  of  the  local  inflammation,  at  least  in  the  typical  and  uncom- 
plicated cases.  Gangrenous  destructive  j^rocesses,  abscess  formation, 
etc.,  take  place  in  exceptional  cases,  and  are  then  complications  of  the 
local  disease. 

Etiology  of  Erysipelas — Streptococcus  of  Erysipelas.— The  ndcro-or- 
ganism  of  erysipelas  is  generally  a  streptococcus  (Figs.  25(),  257,  and 
266)  which  was  first  obtained  in  pure  cultures  by  Fehleisen.  If  man 
or  animals  are  inoculated  with  this  streptococcus  true  erysipelas  will 
result.     I  have  produced  in  animals  (rabbits)  true  erysipelas  by  inocu- 


H7 


340  INFLAMMATION  AND  INJURIES. 

lating  them  with  the  contents  of  erj^sipelas  Webs.  The  streptococcus 
erysipelatis  is  found  almost  everywhere,  particuhirly  in  the  air  of  sur- 
gical wards  (Eiselsberg). 

Tissues  affected  by  this  disease,  when  examined  by  the  microscope, 
reveal  the  erysipelas  coccus,  especially  in  the  lymph  spaces  of  the  skin 

and  subcutaneous  cellular  tissue,  but 

_  „.         it  is  usually  not  to  be  found  in  the 

%    blood-vessels.     Xot  infrequently  there 

' r  will  be  large  groups  of  the  streptococ- 

/^  cus    present.      Recent    investigations 

have  demonstrated  that  Fehleisen's 
erysipelas  coccus  is  identical  with  the 
streptococcus  pyogenes  described  on 
^,  /'   _  /^  P^g6  323,  and  neither  coccus  can  be 

distinguished  from  the  other  in  any 
way.  The  description  of  the  erysipe- 
las coccus  is  given  on  page  323  (strep- 
tococcus pyogenes).  In.  erysipelas,  as 
mentioned  before,  the  sti'eptococciis 
Fig.  266.-Streptococci  of  erysipelas,    x    gi'ows  mainly  in  the  Smaller  lymphat- 

700     Section  through  a  lymph  vessel     •  f    ^}         ^      and  SubcutauCOUS  Cell- 

ot  the  skin  (Fluggej. 

ular    tissue,    while    in circumscribed 

suppurative  processes  the  coccus  is  found  more  in  the  tissues  them- 
selves. Suppuration  and  abscess  occur  in  erysipelas,  in  all  probability, 
'when  the  streptococci  develop  in  large  numbers  in  the  tissues  out- 
side of  the  lymph  channels,  or  when  there  is  a  mixed  infection — in 
other  words,  when  the  staphylococcus  pyogenes  aureus  or  other  pus 
cocci  are  present  in  addition  to  the  streptococcus  pyogenes.  The  ery- 
sipelas which  is  complicated  by  gangrenous  destructive  processes  is 
also  probably  caused  by  a  mixed  infection.  Jordan  and  others  maintain 
that  erysipelas  can  also  be  caused  by  the  staphylococcus,  thus  making 
erysipelas,  from  a  bacteriological  standpoint,  a  non-specific  disease  as 
regards  its  etiology.  Kaltenbach  and  others  have  made  the  interesting 
observation  that  erysipelas  or  tbe  erysipelas  coccus  can  be  transmitted 
from  the  mother  to  the  foetus  in  uiero.  Bostroem  has  also  demon- 
strated the  fact  that  erysipelas  cocci  may  enter  the  blood.  He  saw  an 
acute  catarrhal  pneumonia  develop  in  conjunction  with  a  facial  ery- 
sipelas, and  after  death  the  lymphatic  vessels  in  the  lungs  were  found 
filled  with  streptococci.  The  systemic  intoxication,  the  fever  in  ery- 
sipelas, is,  in  the  main,  the  result  of  the  entrance  into  the  circulation 
of  the  metabolic  products  of  the  streptococci.  The  streptococci  them- 
selves cannot,  as  a  rule,  be  demonstrated  in  the  blood. 


^71.]  ERYSIPELAS.  341 

Erysipelas  of  Mucous  Membranes. — Erysipelatous  inflammations  occur 
not  only  iii  tho  external  cutaneous  coverings  of  the  body  but  also  in 
mucous  membranes,  especially  the  adjoining  mucous  membranes  of  the 
npse,  mouth,  and  their  adnexa,  the  trachea,  the  female  genital  tract,  and 
the  rectum,  A  cutaneous  erysipelas  may  have  involved  these  mucous 
membranes  in  its  course,  or,  on  the  other  hand,  an  erysipelatous  in- 
flammation may  originate  in  the  mucous  membranes  and  extend  from 
them  to  the  skin  in  the  form  of  a  true  erysipelas.  Erysipelas  is  a 
true  infectious  disease  of  wounds — i.  e.,  it  originates  from  some  inter- 
ruption of  continuity  which  may  be  of  the  most  insignificant  character. 
Erysi])elas  does  not  originate  spontaneously  in  the  sense  that  used  to 
be  understood  by  the  term.  But  there  are  forms  of  erysij^elas — for  in- 
stance, in  systemic  pyaemic  poisoning — which  have  a  metastatic  origin. 
From  any  cellulitis^a  capillary  lymphangitis,  in  other  words,  an  erysipe- 
las, may  begin  if  the  streptococci  find  lodgment  and  undergo  subse- 
quent development  in  the  lymphatics  of  the  skin  and  subcutaneous 
cellular  tissue. 

Location  of  Erysipelas. — As  i-egards  the  localities  affected  by  ery- 
sipelas, it  occurs  most  frequently  upon  the  face,  often  starting  from 
some  superficial  abrasion  of  the  skin,  an  ulcer  in  the  nose,  etc.  Some- 
times erysipelas  cases  occur  in  such  numbers  in  some  particular  locality 
or  in  some  hospital  that  the  disease  becomes  epidemic,  or,  rather,  en- 
demic. Like  every  infectious-wound  disease,  erysipelas  has  become 
less  common  since  the  general  use  of  antiseptic  methods,  and  by  strict 
asepsis  it  is  possible  to  absolutely  prevent  an  outbreak  of  erysipelas  in 
a  recent  non-infected  wound. 

Symptomatology  of  Erysipelas. — The  clinical  picture  of  true,  uncom- 
plicated, cutaneous  erysipelas  is  in  the  majority  of  instances  character- 
ised by  the  sudden  occurrence  of  a  rapidly  rising,  generally  severe 
febrile  movement  which  goes  hand  in  hand  with  the  erysipelatous  in-  y, 
flammation  of  the  skin.  Subsequently  there  is  just  as  rapid  a  defer-  ^' 
vescence,  the  temperature  falling  to  the  normal  or  below^it  when  the 
local  erysipelatous  inflammation  approaches  its  termination. 

At  the  beginning  of  a  true  cutaneous  erysipelas  there  will  be  noted 
the  gradual  appearance  of  a  diffuse,  somewhat  ejevated  reddening  of 
the  skin  in  immediate  proximity  to  some  small  or  large,  recent  or  old, 
granulating  or  ulcerated  Avound  of  the  skin.  Frequently  no  wound  of 
the  skin  can  be  made  out  at  all  ;  a  slight  cutaneous  abrasion  may  have 
already  healed.  In  other  cases  the  point  at  which  the  streptococci  of 
erysipelas  have  entered  may  be  found  in  some  adjoining  mucous  mem- 
brane or  in  some  widely  removed  region.  The  redness  is  at  the  outset 
apt  to  be  in  spots,  which  often  appear  as  though  the  lymphatic  network 


342  INFLAMMATION  AND  INJURIES. 

had  been  injected  with  some  red  material  It  was  mentioned  before 
that  the  streptococci  of  erysipelas  spread  mainly  in  the  lymph  channels 
of  the  skin  and  subcutaneous  cellular  tissue.  The  original  spots  very 
soon  coalesce,  forming  an  even,  diffuse  redness.  Sometimes  the  redden- 
ing of  the  skin  may  start,  as  has  been  said,  at  a  greater  or  less  distance 
from  a  wound  or  interruption  of  continuity  in  the  epidermis,  and  under 
such  conditions  the  red  stripes  of  a  lymphangitis  will  connect  the 
wound,  on  the  fingers  or  toes,  for  instance,  with  the  commencing  red 
spot  on  the  arm  or  on  the  leg  or  thigh  (see  Lymphangitis,  §  68).  The 
erysipelatous  redness  and  swelling  extend  steadily  now  in  this  and  now 
in  that  direction ;  they  migrate,  and  may  involve  large  areas  of  skin, 
or  even  the  entire  body,  depending  upon  the  intensity  of  the  disease. 
The  areas  of  skin  first  affected  begin  to  turn  pale  again  after  the  lapse 
of  about  two  to  four  days,  and  sometimes  earlier.  In  the  regions 
where  the  skin  is  firmly  attached  to  the  underlying  parts,  to  the  bones 
or  fascia,  the  erysipelas  is  apt  to  come  to  a  standstill.  Erysipelas  gen- 
erally extends  progressively,  though  in  cases  of  rapid,  wandering  ery- 
sipelas the  disease  may  sometimes  skip  over  an  area  of  skin — for  in- 
stance, in  erysipelas  of  the  foot — a  large  erysipelatous  patch  may  sud- 
denly appear  in  the  region  of  the  knee  or  thigh,  and  then  soon  after- 
wards coalesce  with  the  patch  on  the  foot.  Under  these  conditions  the 
two  foci  of  erysipelas  are  usiially  connected  by  red  stripes  (lymphangit- 
is). Occasionally,  especially  when  occurring  as  a  complication  of  pyaemia, 
there  will  be  observed  the  so-called  erratic,  or,  better,  multiple  erysipelas, 
which  makes  its  appearance  by  metastasis  upon  different  parts  of  the  body. 

The  erjsipelatous  reddening  of  the  skin  ordinarily  exhibits  different 
tinges,  varying  from  a  bright  to  a  dark  red  colour.  In  weak  individu- 
als, or  when  complicating  pulmonary  or  cardiac  affections  (disturbances 
of  circulation),  or  just  before  death  or  as  the  first  stage  of  local  death 
of  tissue,  the  erysipelas  has  more  of  a  bluish  colour. 

If  there  are  gastric  complications,  or  if  occurring  in  drunkards,  the 
cutaneous  redness  occasionally  assumes  a  yellowish  shade. 

The  swelling  in  an  area  affected  by  erysipelas  is  usually  uniform, 
and  the  pjin  in  the  majority  of  cases  is  slight,  but  is  increased  on 
pressure  with  the  finger.  Wherever  the  skin  is  superimposed  upon 
distensible  loose  tissue  there  will  be  a  marked  erysipelatous  exudation, 
as  in  the  scrotum,  penis,  the  female  genitals,  the  eyelids,  or  the  lips. 
As  a  result  of  the  saturation  of  the  superficial  layers  of  the  cutis  with 
serum  during  the  course  of  an  erysipelas  there  will  often  develop 
smaller  or  larger  blebs,  at  the  outset  containing  a  clear  serous  fluid, 
and  later,  for  the  most  part,  pus.  The  blebs,  as  a  usual  thing,  very 
soon  dry  up  and  form  crusts. 


§<!•] 


ERYSIPELAS. 


343 


The  extension  of  the  erysipela.s  takes  place  now  from  this  and  now 
fi^jin  that  border;  it  strides  forward  like  a  tire;  it  wanders,  and  hence 
the  name  erj'sipelas  migrans  or  anibiilans.  For  several  days  the  ery- 
sipelas may  spread  in  some  particular  dii'ection,  and  then  the  process 
ceases  and  begins  to  spread  from  another  border.  It  acts  like  a  fire 
which  cannot  be  controlled  and  which  continues  to  burn  wherever 
there  is  food  for  it,  and  the  flame  may  suddenly  again  break  out  in  a 
region  where  it  seemed  quenched.  Pfleger  thinks  that  the  spread  of 
erysipelas  in  a  particular  direction  depends  upon  the  course  of  the 
linear  furrows  of  the  skin.  The  rapidity  with  wliich  the  erysipelatous 
inflammation  extends  varies  greatly,  moving  forward  sometimes  one  to 
two  centimetres  within  twenty-four  hours,  again  four  to  eight  or  fifteen 
to  twenty  centimetres  and  more.  Eventually,  in  the  great  majority  of 
cases,  the  inflammatory  redness  and  swelling  terminate  in  a  complete 
restitutio  ad  iutegruinj  but  suppuration  may  occasionally  take  place 
and  multiple  abscesses  may  form,  or  as  a  result  of  very  pronounced 
swelling  or  from  the  extension  of  the  disease  to  the  deeper  parts  the 
erysipelas  may  become  complicated  by  phlegmonous  changes,  with  ex- 
tensive or  limited  death  of  tissue  (erj-sipelas  phlegmonosum,  erysipelas 
gangrenosum).  A  process  the  reverse  of  this  sometimes  takes  place — 
i.  e.,  a  deep-spreading  cellulitis  may  come  to  the  surface  and  run  its 


Pifls 

I    Tage:     1 

2 

3         4 

5 

6 

1 

8 

9    1    10 

tl 

1        180 

170 

160 

liiO 

IW 
130 
120 

no 

100 
90 
80 

,70 

1 

fa 

f    cv 

f   a 

r 

a. 

f    CL 

r 

a 

f  a 

f 

a 

f\a 

f.   U 

/■« 

1 41,5 

UlLo 

'. 40.5 

j       40,0 

1 30.5 

39.0 

38.5 

38.0 

33.5 

37,0 
36,5 

« 

A 

•^^ 

^\ 

\^ 

^ 

r 

^ 

\ 

1 

\ 

— 

\l 

/ 

\ 

\ 

\ 

1 

-^ 

— 

— 

1 

, 

\ 

/ 

\ 

/ 

\ 

3 

/  1 

\ 

\ 

:t 

^ 

/ 

H 

ec/c 

'■" 

v 

/ 

1 

_ 

2^ 

__ 

_ 

Fig.  267.-  1,  Temperature-curve  of  an  erysipelas  la.^ting  two  days  with  a  sudden  typical  fall  of 
temperature ;  2,  temperature-curve  of  an  erysipelas  with  temporary  fall  of  the  temperature 
followed  by  a  relapse  of  the  erysipelas ;  recovery. 

course  as  an  erysipelas  of  the  skin.     It  has  already  been  stated  that  in 

the  complicated  cases  of  erysipelas  there  is  usually  a  mixed  infection, 

due  to  the  streptococcus  and  other  bacteria. 

The  general  constitutional  symptoms  correspond  to  the  intensity 

and  extent  of  the  local  process.     The  rise  of  temperature  begins,  as  a 
23 


344  INFLAMMATION  AND  INJURIES. 

rule,  suddenly  and  ratlier  violently,  with  one  or  more  chills,  and  sub- 
sequently, when  the  erysipelas  ceases,  the  temperature  returns  to  the 
normal  with  equal  rapidity.  At  the  height  of  the  disease  the  tem- 
perature generally  rises  to  about  40°  C.  (104°  F.)  or  more,  and  in  ex- 
ceptional cases  it  may  reach  42°  C.  (107"6°  F.).  The  fever  may  have 
either  a  continuous,  a  remittent,  or  an  intermittent  type  (see  pages  258, 
260).  Yery  often  there  will  be  pronounced  gastric  symptoms  ;  the  re- 
gions over  the  liver  and  stomach  are  tender  on  pressure,  there  is  total 
loss  of  appetite,  with  nausea  or  vomiting,  the  thirst  is  ordinarily  exces- 
sive, the  tongue  is  heavily  coated,  dry,  etc.  The  spleen  is  frequently 
much  swollen  ;  sometimes  there  is  pain  in  the  region  of  the  kidneys, 
the  urine  is  generally  dark  coloured,  and  may  contain  albumen,  blood, 
bile  pigment,  and  micrococci,  and  its  quantity  is  diminished.  If  the 
erysipelas  has  a  fatal  termination,  death  is  either  the  result  of  the  gen- 
eral systemic  poisoning  by  the  products  of  the  metabolism  of  the 
bacteria,  or  it  is'caused  by  some  local  complication,  such  as  the  exten- 
sion of  the  erysipelas  to  some  vital  organ,  to  the  cranial  cavity,  for 
example.  Occasionally,  if  the  erysipelas  is  protracted  for  a  great  length 
of  time,  the  gradually  increasing  exliaustion  of  the  patient  may  he  the 
direct  cause  of  death,  which  may  take  place  suddenly  after  convales- 
cence has  begun. 

There  is  no  typical  time  of  duration  for  an  erysipelas,  and  recur- 
rences are  very  common.  The  erysipelas  may  appear  to  have  come  to 
an  end  and  then  it  will  suddenly  start  up  again.  Its  duration  varies 
between  hours  and  weeks.  There  are  well-marked  cases  of  erysipelas 
lasting  twenty- four  hotirs,  and  even  a  less  time,  and  others  which  con- 
tinue for  a  week,  witli  now  greater  and  now  less  intensity,  and  which 
may  eventually  involve  the  entire  body,  and  possibly  attack  the  same 
locality  several  times.  The  average  duration  of  erysipelas  amounts  to 
about  six  to  eight  to  ten  days,  but,  as  Billrotli  says,  it  is,  as  a  general 
thing,  unusual  for  the  disease  to  continue  more  than  fourteen  days. 

Habitual  Erysipelas. — Many  individuals  are  subject  to  what  is  called 
habitual  erysipelas,  a  form  of  the  disease  recurring  more  or  less  period- 
ically upon  some  particular  portion  of  the  body,  most  commonly  the 
face,  and  resulting  very  often  from  a  chronic  nasal  catarrh  which  is 
accompanied  bv  ulceration. 

Complications  of  Erysipelas. — As  complications  of  erj'sipelas,  there 
may  be  marked  disturbances  of  the  central  nervous  system  due  to  the 
high  fever  or  general  systemic  poisoning,  particularly  in  an  erysipelas 
of  the  head,  which  gives  rise  to  meningitis.  "When  the  latter  con- 
dition arises,  there  will  be  at  the  outset  very  marked  symptoms  of 
irritation,  headache,   vomiting,  delirium,  stupour,  and  finally  convul- 


§  71.]  ERYSIPELAS.  345 

sions.  Exceptionally,  even  wlien  convalescence  has  begun,  and  after 
the  erysipelas  and  the  fever  have  almost  completely  vanished,  there 
will  be  observed  in  excitable  persons  a  'state  of  collapse  with  delirium 
of  a  more  or  less  maniacal  nature,  accompanied  by  illusions  and  halluci- 
nations of  sight  and  hearing,  the  so-called  collapse  delirium.  This  tem- 
porary aberration  of  mind  lasts  usually  only  a  few  days.  More  rarely 
there  are  paralyses  of  the  peripheral  nerves  as  a  result  of  central  dis- 
turbance, or  from  peripheral  neuritis  caused  by  thp  erysipelatous  in- 
flammation. Leyden  and  Ken  vers  observed  an'lataxia  of  the  lower 
extremities  which  lasted  a  considerable  time  and  followed  the  exten- 
sion of  an  erysipelas  of  the  head  on  to  the  back. 

The  most  important  of  the  local  complications  which  may  arise  are 
suppuration  and  gangrene,  and  the '"combination  with  an  inflammation 
of  a  phlegmonous  character.  The  number  of  nmltiple  abscesses  which 
may  make  their  appearance  in  the  stage  of  convalescence  is  compara- 
tively large — twenty  to  thirty  or  more,  Landouzy  saw  as  a  result  of 
an  erysipelas  involving  the  face,  hairy  portion  of  the  scalp,  the  neck 
and  back,  sixty-nine  abscesses,  and  some  of  them  in  areas  which  had 
not  been  affected  by  the  erysipelas.  Occasionally  the  suppurative 
process  is  more  diffuse  in  its  nature,  and  extends  inwards,  leading  to 
suppuration  of  the  muscles,  tendon  sheaths,  joints,  etc,  (erysipelas 
phlegmonosum).  The  erysipelatous  joint  suppurations  appear  either 
at  the  outset  and  run  a  very  acute  course,  or  they  first  make  their  ap- 
pearance during  convalescence.  Mention  should  also  be  made  of  phle- 
bitis, lymphadenitis,  and  abscesses  of  the  lymph  glands.  The  lymph 
glands'  are  usually  swollen  at  an  early  stage  of  the  disease.  Gangre- 
nous processes  occurring  in  a  true  erysipelas  are  rare  and  generally 
of  limited  extent,  and  only  extensive  and  severe  when  the  erysipelas  is 
complicated  by  changes  of  a  phlegmonous  character  {E.  gangrenosum). 
Amongst  the  other  local  complications  which  may  arise,  the  diseases 
which  may  affect  the  eye  should  be  included,  such  as  impaired  vision, 
rarely  temporary  blindness,  panophthalmia  with  atrophy  or  suppura- 
tion of  the  eyeball,  particularly  when  a  facial  erysipelas  spreads  to  the 
cellular  tissue  of  the  orbit,  iritis,  ulcerative  processes  of  the  cornea, 
retinitis,  and  optic  neuritis  with  atrophy  of  the  optic  nerves.  There 
may  also  be  catarrhal  and  suppurative  processes  affecting  the  ear, 
inflammation  and  suppuration  of  the  parotid  gland,  dysphagia,  and 
sometimes  changes  in  the  pharynx  simulating  diphtheria.  Occasion- 
ally an  inflammation  of  the  lungs  is  produced  (erysipelatous  pneu- 
monia). Plenris}'  and  cardiac  affections  (pericarditis,  endocarditis,  and 
myocarditis)  are  not  common.  Amongst  the  gastro-intestinal  compli- 
cations which  may  arise  are  ulcerations  of   the  small  intestine,  and 


316  INFLAMMATION  AND   INJURIES. 

transitory  liypergeinia  of  the  intestinal  mucous  membrane  accom- 
panied by  bloody  diarrhoea,  A  similar  condition  may  occur  in 
patients  who  have  i-eceived  burns,  and  I  have  seen  it  in  con- 
junction with  extensive  carbolic  erythema  (see  page  154).  The  liver 
and  spleen  only  exceptionally  give  rise  to  complications.  Jaundice 
due  to  gastritis  may  occasionally  be  present,  but  hsematogenous  jaun- 
dice can  also  occur  in  severe  cases  of  erysipelas  as  a  result  of  the 
poisoning  of  the  blood  by  the  products  of  the  bacterial  metabolism, 
and  this  is  usually  a  precursor  of  speedy  death.  IS^ephritis  is  of  ten  pres- 
ent as  a  complication,  but  it  is  generally  of  a  temporary  nature ;  only 
in  very  exceptional  cases  is  the  acute  erysipelatous  nephritis  so  marked 
as  to  cause  uraemia.  The  latter  is  particularly  dangerous  when  occur- 
ring in  individuals  already  affected  by  kidney  disease  before  they  were 
attacked  by  erysipelas.  Eij^ipelas  is  sometimes  complicated  by  pyae- 
niia  and  septicaemia  (see  §§  74  and  75),  and  occasionally,  as  has  been 
stated,  erysipelas  will  occur  in  the  course  of  a  pyaemia. 

Behaviour  of  the  Wound  in  Erysipelas.— The  interruption  of  con- 
tinuity from  which  the  erysipelas  has  sprung  seldom  manifests  any 
complications.  The  healing  of  the  wound  per  primarn  intentionem  is 
not  often  disturbed  ;  but  the  healing  may  sometimes  be  only  apparent, 
and  the  wound  may  only  unite  superficially,  while  in  its  deeper  parts 
there  will  be  a  retention  of  the  secretion  or  of  pus.  A  granulating 
wound  will  often  exhibit  a  dry  or  dirty  appearance,  and  may  be  cov- 
ered by  a  peculiar  croupous  diphtheritic  membrane.  Erysipelas  has 
occasionally  been  complicated  by  hospital  gangrene  (§  72),  especially 
before  antisepsis  was  introduced. 

The  Healing  Effect  of 'Erysi^ela,s  {Curative  Eri/sipelas). — Great  inter- 
est attaches  to  the  influence  exerted  by  an  intercurrent  erysipelas  of 
the  skin  upon  new  growths,  particularly  those  of  a  lupoid  or  syphilitic 
nature,  with  or  without  ulceration,  and  also  upon  tumours,  such  as  sar- 
coma and  carcinoma.  It  has  been  noticed  that  the  above-mentioned 
formations  may  permanently  disappear,  and  that  ulcers  of  long  standing 
and  chronic  skin  diseases,  which  resisted  every  kind  of  treatment,  have 
improved  and  were  healed  after  an  erysipelas  had  passed  over  them. 
The  French  have  given  the  appropriate  name  of  erysipele  salutaire  to 
an  erysipelas  which  acts  in  this  way,  and  numerous  observations  are 
recorded  in  literature  upon  the  healing  powers  of  erysipelas  for  all  sorts 
of  diseases.  W.  Busch,  in  particular,  has  recorded  some  very  remark- 
able facts  relating  to  the  curative  effect  of  erysipelas  upon  large  tumours 
(sarcomata,  lymphosarcomata),  and  he  showed  that  the  tumours  under- 
went a  rapid  and  extensive  fatty  metamorphosis,  and  could  thus  be 
absorbed  and  completely  disappear.     The  curative  power  of  erysipelas 


§71.]  ERYSIPELAS.  347 

over  tuiuoiirs  lias  been  repeatedly  made  use  of  artificially  for  the  pur- 
pose of  destroyiiii:;  inoperable  new  growths.  If  inoenltition  of  erysip- 
elas is  to  be  practised  on  any  patient,  it  must  be  borne  in  mind  that  the 
course  of  this  disease  cannot  always  be  held  under  control,  and  that 
there  is  a  possibility  of  a  fatal  termination,  as  many  cases  testif}'.  And 
although  it  is  certainly  justifiable  to  produce  erysipelas  artificially  for 
the  purpose  of  curing  an  inoperable  tumour,  the  patient  should  always 
be  informed  beforehand  of  the  danger  of  the  treatment.  P.  Bruns  has 
recently  made  a  critical  investigatittn  of  the  curative  effects  of  erysipe- 
las upon  tumours,  and  succeeded  in  collecting  twenty-two  cases  from 
literature.  There  was  a  complete  and  permanent  cure  in  three  cases 
of  sarcoma,  in  two  cicatricial  keloids,  and  in  a  few  lymphomata.  In 
Bruns's  own  case  a  perfect  recovery  was  brought  about  from  a  recur- 
ring melano-sarcoma  of  the  mamma.  In  one  case,  observed  by  Janicke 
and  AVisser,  in  which  erysipelas  inoculation  was  practised  for  an  in- 
operable carcinoma  of  the  breast,  it  could  be  demonstrated  with  the 
microscope  that  the  erysipelas  cocci  actually  destroyed  the  cancerous 
cells.     Consequently  it  is  possible  for  erysipelas  to  cure  a  carcinoma. 

Ferret  observed  the  complete  absorption  within  six  days  of  the 
callus  surrounding  an  already  united  fracture  of  the  thigh,  so  that  the 
fragments  again  became  as  freely  movable  as  at  the  time  of  fracture. 
There  is  one  other  curious  fact  ascertained  by  Emmerich,  Pawlowsky 
and  Di  Mattei  which  should  be  mentioned  in  this  connection.  If  rab- 
bits and  guinea-pigs  are  inoculated  with  erysipelas,  during  the  ensuing 
three  to  ten  days  they  will  be  unsusceptible  to  (immune  from)  anthrax  ; 
but  after  the  lapse  of  this  period  the  system  is  so  weakened  by  its  con- 
flict with  the  erysipelas  cocci  that  when  the  animal  is  infected  by  anthrax 
for  the  second  time  it  succumbs  more  easily  and  rapidly  than  it  normally 
would ;  in  other  words,  after  the  lapse  of  this  period  the  animal  is  no 
longer  immune  from  anthrax. 

Erysipelatous  Inflammations  of  the  Mucous  Membranes. — Inflamma- 
tions analogous  to  cutaneous  erysipelas  occur,  as  has  been  stated,  in 
the  mucous  membranes  which  adjoin  the  skin,  and  consequently  in  the 
oral  cavity  and  its  adnexa  (nose,  pharynx,  larynx),  in  the  female  genital 
tract,  and  in  the  rectum.  Erysipelatous  M'andering  pneumonia  is  de- 
scribed in  books  on  internal  medicine. 

Diagnosis  of  Erysipelas. — The  diagnosis  of  the  ordinary  cutaneous 
ei'ysipeJas  is  very  simple  in  typical  cases,  and  can  hardly  cause  any 
trouble.  The  gradually  spreading  local  redness  and  swelling  of  the 
skin  and  the  accompanying  fever  are  so  characteristic  that  there  can 
scarcely  be  any  confusion,  even  with  the  exanthemata.  Erythema 
bears  the  closest  resemblance  to  erysipelas,  but  in  erythema  there^is 


348  INFLAMMATION  AND  INJURIES. 

usually  no  fever,  and  the  swelling  and  pain  are  not  nearly  so  pro- 
nounced as  in  erysipelas. 

Prognosis. — In  general,  the  jjrognosis  of  erysipelas  is  not  unfavour- 
able, but  in  no  case  of  this  disease,  no  matter  liow  mild  it  may  seem, 
can  we  be  certain  of  a  satisfactory  termination.  There  are  many  cir- 
cumstances which  affect  the  prognosis  of  an  erysipelas,  particularly  its 
location,  the  constitution  and  age  of  the  patient,  the  complications 
which  may  arise,  the  intensity  and  duration  of  the  local  disease,  and  of 
the  fever,  etc.  The  more  extensive  the  inflammation  the  higher  the 
fever,  and  the  longer  it  lasts  so  much  the  worse  is  the  prognosis.  The 
mortality  given  by  various  authors  differs  very  much,  the  average  being 
about  eleven  per  cent. 

Treatment  of  Erysipelas.— A  great  number  of  remedies  have  been 
employed  for  erysipelas,  and  the  fact  that  the  treatment  varies  so  much 
shows  that  nothing  is  entirely  satisfactory  ;  and  it  is  my  opinion  that,  as 
yet,  we  have  no  very  reliable  and  effective  method  of  treatment.  Since 
the  disease  has  no  typical  duration,  it  is  very  natural  that  mistakes 
should  be  made  in  regard  to  the  curative  power  of  this  or  that  remedy. 

The  best  way  of  preventing  erysipelas  consists  in  treating  every  in- 
terruption of  continuity,  whether  recent  or  old,  large  or  small,  upon 
antiseptic  or  aseptic  principles;  and  wdienever  a  dressing  is  changed  it 
should  be  done  with  a  careful  observance  of  the  rules  of  antisepsis. 

I  believe — and  my  opinion  is  sustained  by  the  experiments  of  Robert 
Koch — that  bichloride  of  mercury  is  the  most  reliable  antiseptic  for  use 
in  dirty  infected  wounds,  to  prevent  infectious-wound  diseases.  Fehl- 
eisen  states  that  cultures  of  the  erysipelas  coccus  are  completely  de- 
stroyed when  subjected  for  ten  to  fifteen  seconds  to  the  action  of  a  1 
to  1,000  solution  of  bichloride.  Erysipelas  never  occurs  after  opera- 
tions which  have  been  performed  with  the  strictest  attention  to  asepsis. 
We  avoid  the  free  use  of  poisonous  antiseptics  in  performing  aseptic 
operations,  though  they  were  formerly  much  in  vogue.  They  are  not 
necessary  if  the  rules  of  asepsis  are  understood  and  followed — in  other 
words,  if  everything  which  comes  in  contact  with  the  wound  is  made 
absolutely  germ  free  (sterilised).  "When  the  erysipelas  has  broken  out, 
the  treatment  should  be  directed  against  the  general  febrile  disturb- 
ance and  the  local  disease.  The  treatment  of  the  fever  has  been  dis- 
cussed in  §  62. 

The  treatment  of  the  local  disease  consists  in  placing  the  affected 
portion  of  the  body  in  a  suitable  position,  and  in  the  application  of  ice, 
particularly  if  the  erysipelas  involves  the  head.  By  painting  the  ery- 
sipelatous area  with  oil  and  covering  it  with  cotton  the  tension  and 
pain  will  be  lessened. 


^71.]  ERYSIPELAS.  349 

It  is  an  excellent  plan  to  use  the  parcncltymatous  injections  of  a 
two-  to  three-per-cent.  solution  of  carbolic  acid  at  the  margins  of  the 
inflamed  district,  which  llueter  has  recommended,  particularly  in  the 
beginning  of  the  erysipelas.  The  contents  of  three  to  five  hy])odermic 
syringes  filled  with  this  solution  are  injected  into  the  sound  skin  imme- 
diately adjoining  the  erysipelatous  area ;  and  after  the  acute  stage  of 
the  inflammation  has  passed,  or  while  the  disease  is  spreading,  these 
injections  are  repeated  once  or  twice.  Subcutaneous  injections  of  bi- 
chloride of  mercury  are  also  exceedingly  good.  Petersen  has  employed 
salicylic  acid  injections  with  successful  results;  others  have  done  the 
same  with  cocaine,  and  Zuelzer  has  used  ergotine  (five  to  eight  centi- 
grammes to  equal  parts  of  alcohol  and  glycerine).  Estlander  recom- 
mends subcutaneous  injections  of  morphine,  particularly  when  com- 
bined with  a  daily  painting  of  the  diseased  area  with  tincture  of  iodine. 
Liicke  and  others  have  used  inunctions  of  turpentine  with  success ;  it  is 
rubbed  into  the  diseased  area  of  skin  two  to  three  to  five  times  a  day 
with  a  brush  or  piece  of  cotton.  Strong  tincture  of  iodine  can  be  ap- 
plied with  a  brush  seven  to  eight  times  a  day ;  nitrate  of  silver  (one  to 
four,  or  eight,  or  ten)  is  highly  praised  ;  also  the  application  of  com- 
presses wet  in  a  three-  to  five-per-cent.  solution  of  carbolic  acid,  or  in  a 
five-  to  ten-per-cent.  solution  of  trichlorphenol ;  fift}'  to  eighty  per  cent, 
resorcin  ointment  may  be  spread  over  the  affected  part,  etc.  Heppel 
recommends  painting  the  borders  of  the  erysipelatous  area  with  a  ten- 
per-cent.  alcoholic  solution  of  carbolic  acid,  covering  a  portion  of  skin 
about  two  inches  wide  all  around  the  diseased  spot.  The  following 
methods  have  also  been  recommended  for  treating  the  disease  locally : 
Covering  the  erysijjelatous  area  of  skin  M'ith  ammonium  sulpho-ichthy- 
olicum  mixed  with  equal  parts  of  lard,  or  with  ichthyol  and  vaseline 
(equal  parts),  and  placing  over  this  absorbent  cotton  ;  covering  the  ery- 
sipelatous area  close  up  to  the  surrounding  healthy  skin  with  an  oint- 
ment of  one  part  creolin,  four  of  iodoform,  and  ten  of  lanoline  (Koch 
and  Mracek),  or  with  white  lead,  or  with  a  varnish  of  linseed  oil,  over 
which  some  water-tight  material  is  applied,  etc.  Kiihnast,  from  his 
experiments  in  Kraske's  clinic,  recommends  multiple  scarifications  and 
mcisions,  followed  by  irrigation  with  a  five-per-cent.  solution  of  carbolic  ' 
acid  ;  also  the  application  to  the  erysipelatous  area  of  compresses  wet 
with  a  two-and-a-half-per-cent.  solution  of  carbolic  acid,  the  compresses 
to  be  changed  once  or  twice  a  day.  Riedel  and  Classen  recommend 
scarification,  particularly  at  the  advancing  margins  of  the  erysipelas. 
Scarifications  are  exceedingly  effective,  especially  when  made  chiefly 
or  exclusively  in  the  healthy  adjoining  skin.  Madelung,  W.  Meyer 
and  others  have  obtained  satisfactory  results  from   scarification  and 


350  INFLAMMATION  AND  INJURIES. 

application  of  compresses  wet  in  a  three-  to  five-per-cent.  solution  of 
carbolic  acid  or  in  a  1  to  1,000-3,000  solution  of  bichloride  of  mercury. 
This  latter  method  of  treatment  is  coming  more  and  more  into  favour 
at  present.  Larrey  preferred  to  make  linear  or  punctate  cauterisa- 
tions with  the  red-hot  iron,  aiming  at  retaining  the  erysipelas  within 
the  barriers  made  by  the  eschars.  AVolfler  has  prevented  the  spread 
of  an  erysipelas  by  means  of  the  mechanical  compression  produced  by 
placing  strips  of  adhesive  plaster  around  its  borders.  For  the  same 
purpose  JS^iehans  employed  collodion,  applying  the  latter  around  an 
extremity  over  a  space  about  two  handbreadths  in  width,  thus  encircling 
the  extremity  with  the  collodion  as  with  a  bandage.  Kroell  recom- 
mends strips  of  caoutchouc  for  the  same  purpose.  vWiniwarter  and 
Fraipont  speak  well  of  the  following  method  of  treatment :  The  part 
affected  by  the  erysipelas  and  the  wound  are  soaked  for  ten  minutes  in 
a  bath  of  1  to  3,000  bichloride,  or  the  latter  is  used  in  the  form  of  an 
irrigation  for  a  longer  period  of  time;  the  erysipelatous  area  is  then 
dried,  and  it  and  the  adjoining  healthy  skin  are  covered  with  tar,  over 
which  is  applied  a  dressing  wet  with  Burow's  solution  (see  page  159); 
then  iodoform  gauze  which  has  been  dipped  in  a  bichloride  solution 
is  placed  on  the  wound,  and  the  whole  dressing  is  bandaged  lightly  in 
position. 

It  has  been  attempted  to  combat  the  erysipelatous  inflammation  by 
the  internal  administration  of  drugs.  English  surgeons,  in  particular, 
give  iron  internally  (liq.  ferri  chlorat.,  in  large  doses,  fifteen  to  twenty 
drops  every  hour,  or  even  2'0  grammes  or  more);  others  use  liq.  ferri 
sesquichlorati.,  ten  to  fifteen  drops  every  two  to  three  hours ;  ergotine, 
iodide  of  potassium,  and  belladoima  have  been  used  for  the  same  pur- 
pose, Haberkorn  has  recently  employed  with  success  benzoate  of  sodi- 
um in  mucilaginous  solutions,  or  in  some  effervescing  water,  in  doses 
of  fifteen  to  twenty  grammes  a  day ;  no  local  treatment  is  made  use  of. 
The  effectiveness  of  all  internal  medication  is  exceedingly  doubtful. 
Camphor  (internally  or  in  the  form  of  subcutaneous  injections)  has' but 
little  value,  though  it  was  highly  recommended  by  Pirogoff. 

The  treatment  of  the  complications,  particularly  the  abscesses,  gan- 
grenous processes,  and  the  inflammations  of  joints,  should  be  con- 
ducted on  the  principles  laid  down  for  these  conditions.  At  the  time 
of  the  outbreak  of  the  erysipelas,  or  when  the  case  is  met  with  in  a  later 
stage,  the  ^vound  from  which  the  disease  starts  should  be  carefully  ex- 
amined and  treated  antiseptically,  and  if  any  blood  or  pus  is  held  in 
retention  it  should  be  let  out  by  removing  a  few  sutures,  by  separating 
the  agglutinated  margins  of  the  wound,  b}'  making  incisions,  etc. 
--7   If  it  is  desired  to  inoculate  an  erysipelas  for  therapeutic  purposes 


§72.]  HOSPITAL  GANGREXE— WOUND  DIPIITriERIA.  351 

upon  an  inoperahle  tnnionr  or  other  diseases  of  the  skin,  it  should  al- 
ways be  borne  in  mind  tliat  infection  by  the  streptococcus  of  erysipelas 
may  cause  the  death  of  the  patient. 

Zoonotic  Erysipelas -Wandering  Erythema  {Et'ijtheina  migrans). — 
The  so-called  erysipeloid  or  wandering  erythema  occu^rs  almost  exclu- 
sively on  the  hands,  and  attacks  most  commonly  individuals  avIio 
handle  all  sorts  of  dead  animal  substances,  dealers  in  game  or  fish, 
cooks,  restaurant  keepers,  l)utcliers,  tanners,  oyster  openers,  and  those 
who  come  mnch  in  contact  with  cheese,  herring,  etc.  The  erj'sipeloid 
is  a  disease  of  wounds  which  is  not  very  infectious  in  character,  and 
affects  the  hands  almost  exclusively,  some  infectious  substance  being 
inoculated  into  small  wounds.  After  inoculation  there  ensues  a  mod- 
erate infiltration  of  the  skin,  giving  the  latter  a  dark-red  discolouration  ; 
there  is  no  fever,  and  the  disease  spreads  very  slowly,  with  an  itching, 
prickling  sensation,  and  it  may  take  eight  days  to  extend,  for  instance, 
from  the  finger-tip  to  the  metacarpus.  The  reddening  of  the  skin  more 
often  occurs  in  spots;  less  frequently  it  is  of  a  diffuse  character.  It  is 
only  very  exceptionally  that  the  erysipeloid  extends  as  far  as  the  wrist, 
and  it  never  reaches  the  forearm.  The  disease  is  often  very  stubborn 
and  persistent,  lasting  sometimes  three  to  four  to  six  weeks  unless  proper 
treatment  is  adopted ;  but  in  other  cases  it  may  disappear  spontane- 
ously in  one  to  two  to  three  weeks.  liosenbach  found  that  a  coccus-like 
body  was  the  cause  of  the  erysipeloid ;  it  is  larger  than  the  staphylo- 
coccus, grows  best  in  gelatine  at  a  temperature  of  20°  C,  forms  twisted 
filaments  of  varying  length,  and  bears  a  remarkable  resemblance  to  a 
form  of  microbe  described  by  Cohn  under  the  name  of  cladothrix 
dichotoma.  Kosenbach  and  Cordua  have  produced  this  erysipeloid  by 
inoculations  practised  on  themselves. 

The  best  method  of  treating  the  zoonotic  erysipeloid  consists  in 
cutaneous  injections  of  a  three-per-cent.  solution  of  carbolic  acid  into 
the  inflamed  area  of  skin,  and  into  the  healthy  skin  immediately  adjoin- 
ing its  outer  borders.  / 

§  72.  Hospital  Gangrene — Wound  Diphtheria, — Hospital  gangrene 
{Gangrteim  nosoconiialis).,  or  wound  diphtheria,  used  to  be,  in  the  pre- 
antiseptic  era,  a  very  common  disease,  but  if  antiseptic  treatment  is 
used  it  never  occurs.  Hospital  gangrene  is  a  local  wound  disease,  al- 
ways bacterial  in  its  origin,  and  consists  essentialh^  of  a  gangrenous 
destruction  of  the  granulations  and  adjoining  tissues.  In  the  days 
before  the  dawn  of  antisepsis  it  was  of  very  frequent  occurrence  in 
many  hospitals  with  bad  hygienic  arrangements,  and  was  particularly 
common  in  conjunction  M'ith  contused  wounds  or  those  in  which  there 
was  considerable  extravasation  of  blood,  as  well  as  in  gunshot  wounds. 


352  INFLAMMATION   AND  INJURIES. 

Since  the  introduction  of  antisepsis  liospital  gangrene  has  almost  en- 
tirely disappeared. 

Etiology  of  Hospital  Gangrene. — The  micro-organism  of  hospital 
gangrene  has  not  as  jet  been  discovered ;  but  reasoning  from  the  whole 
course  of  the  disease,  there  can  be  no  doubt  that  we  have  to  deal  with  an 
infectious-wound  disease  caused  by  some  one  of  the  fungi.  Rosenbach, 
in  his  last  monograph  on  hospital  gangrene,  could  give  no  information 
upon  the  exciting  cause  of  the  disease.  The  identity  of  hospital  gan- 
grene and  diphtheria  of  the  pharynx  is  still  an  open  question,  and  many 
arguments  pro  and  con  have  been  advanced  by  different  authors. 
W.  Roser  and  Rosenbach  have  been  tlie  most  outspoken  against  the 
identity  of  the  two  diseases.  The  pathological  changes  in  hospital  gan- 
grene, like  those  in  diphtheria  of  the  pharynx,  consist  in  an  infarct  of 
the  infected  wound,  or  in  a  coagulation  necrosis,  as  it  is  called  by 
Cohnheim  and  Weigert,  in  which  are  present  great  numbers  of  micro- 
cocci and  bacteria  of  decomposition. 

Clinical  Cause  of  Hospital  Gangrene.— Clinically  the  disease  occurs  in 
one  of  three  forms:  1,  The  superficial  croupous  and  diphtheritic;  2,  the 
ulcerative  diphtheritic,  and,  3,  the  pulpy,  the  latter  being  the  most  ma- 
lignant form.  These  different  forms  of  the  disease  may  run  into  each 
other,  and  clinically  cannot  always  be  sharply  distinguished.  The 
croupous  or  diphtheritic  form  of  hospital  gangrene  is  characterised  by 
the  development  of  haemorrhagic  foci  accompanied  by  swelling,'  the 
foci  subsequently  breaking  down  and  forming  a  foul,  suppurating,  jelly- 
like mass.  By  immediate  treatment  of  the  diphtheritic  area  with  a  con- 
centrated chloride-of-zinc  solution,  or  with  the  Paquelin  thermo- 
cautery, the  spread  of  this  lowest  grade  of  hospital  gangrene  can  gen- 
erally be  arrested.  The  ulcerative  form  of  the  disease  also  begins  with 
the  development  of  hsemorrhagic  spots  having  a  grey  or  greyish-yellow 
colour,  and  at  the  outset  is  of  limited  extent ;  but  in  a  relatively  short 
space  of  time  it  spreads  over  the  granulating  surface  and  changes  the 
latter  into  a  grey  or  greyish-yellow  mass,  which  subsequently  breaks 
down  into  a  gangrenous  pulp.  This  gangrenous  destruction  of  tissue 
may  steadily  advance  inwards,  and  superficially  may  involve  the  skin 
adjoining  the  granulating  surface  by  a  spreading  of  the  ulcerative  pro- 
cess. The  ulcerative  form  of  hospital  gangrene  may  change  into  the 
pulpy  or  most  dangerous  kind  of  wound  diphtheria.  In  the  pulpy 
form,  according  to  Konig,  there  occurs,  as  a  general  rule,  a  rapid  swell- 
ing of  the  tissues  in  consequence  of  the  extensive  haemorrhages  into 
the  granulations,  followed  by  putrefaction  of  the  entire  mass  and 
the  evolution  of  gases  of  decomposition.  The  borders  of  the  wound 
are  red  and  very  painful.     The  swollen,  grey,  or  greyish-red  wound 


g72.]  HOSPITAL   GANGRENK— WOUND    DTPIITHKRIA.  353 

looks,  as  Konig  says,  like  a  soft,  decomposing  spleen  or  mass  of  brain 
tissue. 

The  course  of  hospital  gangrene  depends,  in  general,  upon  whether 
the  gangrene  of  the  wound  remains  superficial  or  extends  into  the  moi-e 
deeply  lying  parts.  Every  form  of  hospital  gangrene  may  destroy  the 
skin  and  spread  into  the  subjacent  tissues,  particularly  if  it  is  of  the 
j)nlpy  variety.  The  gangrenous  changes  advance  very  rapidly,  and 
within  twentv-four  hours  cause  the  wound  to  become  double  its  oricfi- 
nal  size,  or  even  larger,  but  in  other  cases  the  changes  take  a  much 
longer  time. 

The  general  symptoms  correspond  to  the  severity  of  the  local  dis- 
ease. The  fever  may  be  continuous  or  remittent,  with  intercurrent 
chills.  Very  frequently  the  local  disease  begins  with  a  rigour  and  a 
fever  of  4<>°  to  41°  0.  ^04°  to  105-8°  F.). 

Prognosis  of  Hospital  Gangrene. — The  prognosis  of  hospital  gangrene 
depends  upon  the  form  of  the  gangrene  and  the  nature  of  the  treat- 
ment. The  pulpy  form  of  hospital  gangrene  has  the  most  unfavour- 
able prognosis  of  all.  The  strength  of  the  patient  and  the  conditions 
under  which  he  has  lived  must  be  taken  into  account.  The  milder 
forms  of  hospital  gangrene  will  often  get  well  spontaneously,  while  the 
more  severe  forms  will  frequently  cause  death  by  general  septic  poi- 
soning, unless  the  spread  of  the  gangrenous  process  is  combated  suffi- 
ciently early  and  energetically  by  proper  treatment.  Recurrences  of 
the  disease  take  place  not  infrequently. 

Treatment  of  Hospital  Gangrene. — The  treatment  of  hospital  gan- 
grene consists  in  the  energetic  use  of  the  Paquelin  thermo-cautery  and 
of  caustics,  particularly  nitric  acid  or  chloride  of  zinc,  to  check  the 
spread  of  the  gangrene.  Deeply  placed  gangrenous  foci  must  be  laid 
open  with  the  knife,  to  permit  the  pns  to  escape  and  to  enable  the  sup- 
purating region  to  be  energetically  disinfected  with  a  1  to  1,000  solu- 
tion of  bichloride  of  mercury.  Iodoform  or  naphthaline  are  excellent 
substances  to  apply  in  the  dressings ;  or,  if  the  gangrene  is  very  exten- 
sive, antiseptic  irrigation  may  be  practised,  as  described  on  pages  178 
and  179.  If  it  becomes  necessary  to  amputate  a  gangrenous  limb,  the 
operation  should  be  performed  with  the  strictest  antiseptic  precautions, 
after  first  energetically  disinfecting  the  gangrenous  focus,  or  burning 
it  with  the  Paquelin  thermo-cautery  and  covering  it  with  an  antiseptic 
dressing  wet  with  bichloride. 

Every  patient  with  wound  diphtheria  should  be  isolated  with  the 
greatest  possible  care,  as  a  protective  measure  for  the  other  patients. 
Hospital  gangrene,  as  has  been  said,  does  not  occur  at  present  with 
the  antiseptic  method  of  treating  wounds ;  but  in  the  time  of  war, 


354  INFLAMMATION  AND  INJURIES. 

where  the  rules  of  antisepsis  cannot  always  be  strictly  observed,  hospi- 
tal gangrene  invariably  makes  its  appearance. 

■  §  73.  Traumatic  Tetanus  {Trismus). — Tetanus  is  an  infectious-wound 
disease  characterised  by  cramp-like  contractions  of  the  muscles  of  the 
lower  jaw  alone  (trismus),  or  by  contractions  of  certain  other  groups  of 
muscles,  or  of  the  muscles  of  the  whole  body  (tetanus).  The  cramps 
may  affect  at  one  time  the  muscles  of  the  extremities,  and  at  another 
the  muscles  of  the  anterior  or  posterior  aspect  of  the  trunk. 

Etiology  of  Tetanus. — There  used  to  be  a  great  many  theories  con- 
cerning the  nature  and  etiology  of  tetanus,  but  they  did  not  account 
satisfactorily  for  its  occurrence  in  the  injured,  and  they  are  to  be 
looked  upon  at  present  as  untenable.  Amongst  them  was  the  reflex 
theory,  which  supposed  that  tetanus  was  excited  rellexly  from  irrita- 
tion of  the  peripheral  nerve  trunks  by  an  injury,  a  foreign  body,  or 
by  the  application  of  a  ligature,  or  that  the  disease  was  due  to  changes 
in  temperature,  or  to  catching  cold,  etc.  Verneuil,  Iloser  and  Ileiberg 
were  the  first  to  affirm  the  infectious  nature  of  tetanus  and  its  causation 
by  absorption  of  a  poison  from  the  wound.  The  recent  investigations 
of  Kicolaier,  Brieger  and  Kitasato  have  proved 
\         .  beyond  a  doubt  that  tetanus  is  produced  by  a 

specific  bacillus  discovered  by  Kicolaier,  and 
first  obtained  in  pure  cultures  by  Kitasato 
(Fig.  268). 

1^  1^1^  ^  The  injuries  which  may  be  followed  by  tet- 

^      V  '^     anus    are   of   every   description.      Sometimes 

^        V    '  they  are  severe,  and  involve  both  soft  parts  and 

Fio.268.-Tetanus  bacilli  with     boneS,  SUch  aS  COmpOUnd    fractures,    and    some- 
spores  from  an  agar  culture    times  less  severe,  such  as  burns,  frost-bites,  or 

(Kitasato).     x  1000.  •      ■       -n         j.  ^         £    .^  ^  ■ 

msignmcant  wounds  oi  the  skin  or  a  granu- 
lating surface,  or  perhaps  only  a  small  punctured  wound,  etc.  Tetanus 
has  been  known  to  come  from  a  blister  and  the  sting  of  a  bee.  We  can 
easily  understand,  from  the  analogous  origin  of  other  infectious-wound 
diseases,  particularly  anthrax,  how  tetanus  may  follow  the  verj"  slightest 
interruption  of  continuity  in  the  skin.  The  disease  is  particularly  apt 
to  occur  as  a  result  of  injuries  to  the  hands  or  feet,  in  which  are  lodged 
foreign  bodies,  such  as  bits  of  earth  or  splinters  of  wood.  Animals,  such 
as  horses,  may  often  be  the  means  of  transmitting  the  tetanus  bacillus 
to  man.  Occasionally  the  disease  appears  to  break  out  after  the  lapse 
of  a  certain  period  of  incubation,  and  consequently  it  is  possible  for 
tetanus  to  occur  after  the  wound  has  entirel}'  healed.  The  disease  ma}' 
become  endemic  under  certain  conditions — for  instance,  in  hospitals 
where  the  rules  of  antisepsis  and  asepsis  are  not  strictly  observed.     In 


.^ 


i: 


r 


§  73.]  TRAUiMATIC  TETANUS.  355 

order  to  got  a  clear  idea  of  tlie  nature  of  tetanus,  attempts  were  made 
to  excite  the  di>ea>e  experimentally  in  animals;  but  all  attempts  at  in- 
oculation failed  until  Kitasato  and  others  finally  succeeded  quite  re- 
cently, thus  making  it  certain  that  tetanus  is  infectious  in  nature. 

Experimental  Inoculation  of  Tetanus  upon  Animals.— Carle  and  Rattone 
excised  from  a  uiiin  wlio  had  died  of  telamis  the  inllamcd  area  of  skin  sur- 
rounthii<,'  an  acne  pustule  from  which  the  disease  had  probably  originated; 
an  emulsion  was  pi-epared  from  the  excised  pustule  and  injected  into  the 
l)erineuriura  of  the  great  sciatic  nerve,  the  spinal  cord,  and  back  muscles  of 
dilfereut  rabbits.  Of  the  twelve  rabbits  inoculated,  eleven  were  seized  with 
true  tetanus  and  died  within  four  days  at  the  latest.  Blood  taken  from  the 
diseased  animals  and  inoculated  upon  healthy  animals  did  not  excite  the 
disease,  but  an  emulsion  made  from  material  taken  from  the  point  at  which 
the  inoculation  was  made  in  the  sciatic  nerve  produced  fatal  tetanus.  Rosen- 
bach  and  others  succeeded  in  transmitting  the  disease  from  man  to  animals 
(guinea-pigsj,  and  from  the  latter  to  other  animals  fguinea-pigs  and  rabbits). 

Nicolaier's  Earth  Tetanus.— Nicolaier  performed  some  very  interesting 
experiments  in  P"liigjre"s  laboratory.  While  carefully  studying  the  micro- 
organisms in  surface  soil,  he  wa>  surprised  to  find  that  a  disease  similar  to 
human  tetanus  was  produced  in  a  considerable  number  of  cases  (sixty- 
nine  times  in  one  hundred  and  forty  experimental  inoculations)  by  inocu- 
lating animals  with  earth  taken  from  widely  separated  sources  (Berlin, 
Wiesbaden,  Leipsic  and  Gottingen).  The  inoculations  with  the  earth  were 
practised  at  the  root  of  the  tail  in  white  and  yellow  mice,  and  beneath  the 
skin  in  rabbits  and  guinea-pigs.  In  mice  after  the  lapse  of  one  and  a  half  to 
two  and  a  half  days,  or  four  to  five  days  in  rabbits,  cramps  occurred  in  the 
muscles  in  the  neighboui'hood  of  the  region  inoculated,  and  later  the  tetanus 
extended  to  the  muscles  of  the  other  extremities  and  to  those  of  the  back  and 
the  nape  of  the  neck.  In  rabbits,  the  muscles  of  the  jaw  became  rigid  in  a 
state  of  tonic  sjiasm,  and  death  occurred  after  the  lapse  of  one  and  a  half  to 
two  da\-s.  Mice  died  twelve  to  twenty  houi'S  after  the  first  symptoms  of  poi- 
soning made  their  appearance.     Dogs  did  not  react  at  all  when  inoculated. 

The  post-mortem  examination  revealed,  as  in  man,  very  little  which  was 
distinctive.  Microscopically,  in  the  slight  amount  of  pus  at  the  point  of  in- 
oculation, micrococci  were  found,  and  particularly  a  peculiar  bristle-shaped 
rod  carrying  spores.  Nicolaier  was  not  able  to  obtain  pure  cultures  of  this 
bacillus;  he  could  not  separate  them  from  other  bacilli,  and  consequently  it 
was  believed  that  tetanus  was  caused  by  a  kind  of  symbiosis  of  different  bac- 
teria. The  bacillus  in  question  was  found  by  itself  in  the  subcutaneous  tis- 
sues, but  Nicolaier  was  almost  never  able  to  demonstrate  microscopically  the 
presence  of  the  bacillus  in  the  more  deeply  lying  muscles  and  neiwes,  includ- 
ing the  blood.  Only  in  a  few  cases  was  he  able  to  find  the  bacilli  in  the 
sheath  of  the  sciatic  nerve  and  in  the  spinal  cord.  When  the  earth 'was 
heated  for  an  hour  the  inoculations  were  unsuccessful.  Attempts  at  pro- 
ducing infection  by  pus  taken  from  animals  at  the  point  where  they  were 
inoculated  succeeded  in  sixty-four  out  of  eighty-eight  experiments,  the  dis- 
ease running  a  more  rapid  course  than  when  earth  was  employed.  Inocula- 
tions with  pieces  of  the  infected  tissues  succeeded  only  fourteen  times  in 


356  INFLAMMATION   AND   INJURIES. 

fifty-two  cases.  Nicolaier  concluded,  from  his  experiments,  that  tetanus  was 
produced  by  the  bacillus  in  question,  which  acted  by  producing  a  poison  like 
strychnine,  and  not  by  simply  increasing  in  numbers. 

Socin  has  also  excited  true  tetanus  by  making  inoculations  with  garden 
earth.  I  saw  one  fatal  case  of  tetanus  following  a  compound  fracture  which 
had  become  befouled  with  earth.  The  patient  came  under  my  care  after 
well-marked  tetanus  had  developed. 

Description  of  ths  Tetanus  Bacillus. — Eitasato  was  the  first  to  isolate 
Nicolaier's  tetanus  bacillus  from  the  other  bacteria  found  accompanying  it ; 
he  cultivated  it  and  excited  tetanus  in  animals  by  inoculating  them  with  the 
pure  culture,  and  thus  established  the  correctness  of  the  suppositions  which 
had  existed  about  the  disease.  Kitasato  i^laced  in  the  necessary  culture  me- 
dium a  small  piece  of  tissue  taken  from  the  immediate  neighbourhood  of  a 
suppurating  wound  in  a  man  who  had  died  of  tetanus.  The  culture  when 
placed  in  the  incubator  revealed  a  luxuriant  growth  of  bacteria;  but  the  kind 
which  carried  spores  at  one  extremity  developed  the  most  rapidly,  whOe  the 
others  only  began  to  gi'ow  after  the  lapse  of  a  certain  length  of  time.  Before 
these  latter  could  develop  Kitasato  heated  the  mixed  culture  to  a  temperature 
of  80'"  C.  and  destroyed  all  the  bacilli  which  had  not  taken  on  their  perma- 
nent form,  leaving  only  those  which  wei'e  capable  of  forming  spores.  From 
these  he  made  a  pure  culture,  which,  when  inoculated  upon  animals,  estab- 
lished the  fact  that  the  bacillus  containing  spores  in  one  of  its  extremities, 
and  first  discovered  by  Nicolaier,  was  actually  the  true  bacillus  of  tetanus. 

Pathogenesis  of  Tetanus. — The  tetanus  bacillus  Ls  a  slender  rod,  somewhat 
longer  though  not  as  large  in  diameter  as  the  bacillus  of  mouse  septicaemia 
(Kochj,  and  is  found  in  the  surface  layers  of  ordinary  earth,  in  decaying 
masonry,  decomposing  fluids,  manure,  or  splinters  of  wood  found  in  wounds, 
and  in  the  pus  from  a  wound  upon  a  person  who  has  died  of  tetanus.  The 
rods  sometimes  form  long  filaments,  upon  which  the  divisions  between  the 
segments  (bacilli)  are  almost  indistinguishable.  The  bacilli,  for  the  most  part, 
collect  in  irregular  groups.  The  tetanus  bacillus  possesses  a  recognisable 
though  slight  power  of  movement,  and  grows  rather  slowly,  best  at  a  tem- 
perature of  36°  to  38"  C.  (96-8°  to  100-4°  F.),  while  below  16°  C.  no  develop- 
ment takes  place.  It  is  obligate  anaerobic — i.  e.,  it  grows  only  when  atmos- 
pheric air  is  absent.  In  the  presence  of  oxygen,  the  bacillus  quickly  died. 
In  an  atmosphere  of  pure  hydrogen,  small  ray-like  colonies  develop  slowly 
upon  gelatine  plates  after  the  lapse  of  some  days:  they  liquefy  the  nutritive 
medium  with  the  evolution  of  gas,  and  present  an  appearance  similar  to  the 
hay  bacillus  (a.  rather  thick,  solid  centre,  with  radiating  filaments).  Stab 
cultures  in  a  test  tuhe  containing  a  considerable  amount  of  grape  sugar 
gelatine,  or  in  gelatine  to  which  has  been  added  0"!  per  cent,  of  indigo-sulphate 
of  sodium,  give  a  culture  at  the  bottom  of  the  tube  having  the  appearance 
illustrated  in  Fig.  269.  At  the  end  of  the  first  week  it  looks  something  like 
a  fir-tree — i.  e.,  numerous  fine  processes  radiate  outwards  from  the  line  of 
puncture,  simulating  the  bacillus  figurans.  Subsequently  the  gelatine  sur- 
rounding the  colony  is  liquefied  and  there  is  an  evolution  of  gas.  In  a  test 
tube  containing  agar,  to  which  has  been  added  one  to  two  per  cent,  of  grape 
sugar  or  indigo-sulphate  of  sodium,  the  growth  at  the  proper  incubation  tem- 
perature is  more  rapid  and  luxuriant,  and  after  the  first  or  second  twenty- 


§73.J 


TRAUMATIC  TETANUS. 


357 


four  hours  the  culture  causes  an  evohition  of  gas  which  has  a  characteristic 
unpleasant  odour.     In  grape-sugar  bouillon  the  growth  of  the  culture  is  ex- 
ceedingly vigorous,  and  is  accompanied  by  the  formation  of 
a  lai'ge  amount  of  gas.     In  blood  serum,  at  a  temperature  of 
34°  to  38°  C,  after  the  lapse  of  one  to  three  days,  small  round 
cavities  develop,  which  gradually  coalesce. 

Spore  formation,  at  a  temperature  of  37°  C,  takes  place  in 
thirty  hours,  and  occurs  at  one  end  of  the  bacillus,  this  por- 
tion of  the  cell  swelling,  and  giving  it  the  appearance  of  a 
drum-stick  (Fig.  268).  The  spores  have  great  vitality,  and 
will  remain  alive  when  exposed  in  a  moist  state  to  a  tem- 
perature of  80°  C.  for  one  hour,  but  are  destroyed  in  live 
minutes  when  exposed  to  steam  at  a  temperature  of  100°  C. 
Dried  pus  containing  spores  i-etains  its  virulence  after  the  ex- 
piration of  sixteen  months.  The  tetanus  bacillus  is  readily 
stained  by  the  ordinary  aniline  dyes.  Gram's  method  can 
also  be  employed. 

If  a  small  amount  of  a  pure  culture  is  inoculated  upon 
mice,  rats,  guinea-pigs,  or  rabbits,  the  former  two  kinds  of  an- 
imals will  manifest  the  first  symptoms  of  the  disease  in  twen- 
ty to  twenty-four  hours,  the  latter  two  in  two  to  three  days. 
If  horses,  sheep,  or  dogs  are  inoculated  with  the  pure  culture 
they  will  develop  typical  tetanus.  The  manifestations  of  the 
disease  are  at  first  local,  and  confined  to  the  parts  immediate- 
ly adjoining  the  point  of  infection,  from  which  they  gradu- 
ally spread,  and  the  animal  then  dies  in  a  short  time.  At 
the  point  of  infection  there  is  infiltration  of  the  tissues  and 
hypera?mia,  but  no  suppuration,  and  sometimes  it  may  be 
possible  to  demonstrate  the  presence  of  the  bacilli;  but  they 
are  never  found  in  the  different  organs  or  in  the  blood.  The 
latter  fact  is  explainable  on  the  ground  that  the  bacilli  form  an  extremely 
active  poison,  which  spreads  rapidly  throughout  the  body.  Brieger  has  ob- 
tained from  tetanus  cultures  four  toxines  in  a  chemically  pure  state :  teta- 
nine  Ci3H3oNa04,  tetanotoxine  CsHuN,  spasmotoxine,  and  a  toxine  hydro- 
chlorate.  Very  small  amounts  of  these  toxines  produce  in  animals  tetanic 
symptoms,  bvit  Weyl  states  that  it  is  not  typical  tetanus. 

The  Tetanus  Poison. — Weyl  and  Kitasato  have  also  attempted  to  isolate 
the  poisonous  substances  from  pure  cultures  of  the  -tetanus  bacillus.  They 
considered  that  Brieger  worked  with  impure  cultures.  Weyl  and  Kitasato 
found  a  very  poisonous  substance  closely  allied  to  the  albuminoid  bodies, 
which  produced,  after  the  lapse  of  a  certain  period  of  incubation,  the  symptoms 
of  tetanus,  though  they  were  not  so  typical  as  after  an  infection  by  the  tetanus 
bacillus.  Brieger,  working  with  E.  Frankel,  has  also  discovered  the  same 
body  (tetanotoxalbumen).  The  toxine,  isolated  at  an  earlier  date  by  Brieger, 
produced  very  acute  tetanic  symptoms,  but  not  the  typical  picture  of  tetanus. 
The  toxic  substance  obtained  from  different  kinds  of  pure  cultures  of  the 
tetanus  bacillus  varies — a  fact  which  corresponds  to  what  we  know  of  other 
bacteriological  investigations.  By  subcutaneous  injection  in  mice,  guinea- 
pigs,  and   rabbits,  of  the  germ-free  filtrate  from  bouillon  cultures  of  the 


Fig.  269.— Tetan- 
U!<  culture.  Stab 
culture  in  g'ela- 
tine  with  indi- 
go -  sulphate  of 
sodium.  Seven 
days  old. 


353  INFLAMMATION   AND   INJURIES. 

tetanus  bacillios,  Kitasato  obtained  a  typical  tetanus  which  terminated  fatally. 
Consequently  intoxication  by  the  tetanus  bacillus  seems  to  be  caused  by  sev- 
eral different  ijoisonous  substances. 

The  poLson  exists  in  the  serum  of  the  blood,  and  after  circulating  through 
the  system  in  this  medium,  it  is  excreted  by  the  kidneys,  which  accounts  for 
the  particularly  toxic  powei-s  of  the  latter  organs.  BriLSchettini  was  able  to 
excite  tetanus  in  healthy  animals  by  injecting  into  them  subcutaneously  the 
urine  taken  from  animals  suffering  from  this  disease.  Testana,  on  the  other 
hand,  was  unable  to  demonstrate  in  the  liver,  spleen  and  kidneys  the  toxic 
substance  of  the  tetanus  bacilli. 

Tetanus  Immunity  in  Animals.— Gi-eat  interest  attaches  to  the  experi- 
ments of  Behring  and  Kitasato  relating  to  the  production  in  animals  of  ira- 
muuity  from  tetanus.  These  authors  succeeded  in  curing  infected  animals, 
and  in  so  treating  healthy  ones  that  they  were  never  afterwards  affected 
by  the  tetanus  bacillus.  The  blood  and  serum  of  rabbits  which  have  been 
rendered  immune  from  tetanus  possess  the  power  of  destroying  the  tetanus 
poison.  They  are  both  prophylactic  and  curative.  By  transfusion  of  blood 
or  serum  remarkable  therapeutic  effects  can  be  obtained — that  is,  infected 
animals  can  be  cured,  and  healthy  ones — mice,  for  example — can  be  rendered 
permanently  immune.  The  artificially  acquired  immunity  is  ti'ansmitted 
from  the  animal  to  the  foetus  in  utero,  and  persists  in  the  young  for  some 
time  after  birth.  Tizzoni  and  Cattani  have  made  white  mice  immune  by  the 
serum  of  the  blood  taken  from  frogs  and  pigeons  which  are  unsusceptible  to 
tetanus  ;  but  Kitasato.  experimenting  w^th  the  blaod  of  chickens,  has  con- 
tested their  assertions.  Kitasato  has  rendered  rabbits  immune  from  tetanus 
by  injections  of  iodoform.  Tizzoni  and  Cattani  state  that  rabbits  from  which 
the  spleen  has  been  removed  cannot  be  made  immune.  The  future  must  de- 
cide whether  the  facts  established  about  the  action  of  blood  semm  in  curing 
animals  affected  with  tetanus  is  of  therapeutic  value  for  man  in  a  similar 
condition.  Vaillard's  exi>eriments  seem  to  make  the  hope  of  success  in  this 
line  rather  doubtful.  Tizzoni,  Cattani  and  others  have  prepared  curative 
serum  fantitoxine)  from  animals  which  have  been  made  immune  from  the 
disease,  and  have  recojnmended  it  for  use  in  man.  As  yet  no  definite  con- 
clusion has  been  reached  wpon  the  success  which  may  be  obtained  by  the 
subcutaneous  injection  of  this  remedy. 

Sormani  gave  pure  cultures  of  tetanus  bacilli  and  the  flesh  of  animals 
dying  of  tetanus  to  herbivora  and  carnivora.  and  both  classes  of  animals  re- 
mained healthy  ;  but  in  the  faeces  of  these  animals,  particularly  the  herbiv- 
ora. he  found  an  active  tetanus  poison  which  was  capable  of  communicating 
the  disease. 

Disinfection  of  Objects  Infected  with  the  Tetanus  Poison.— The  disinfection 
of  all  objects  infected  with  the  tetanus  poison  is  best  carried  out  by  subject- 
ing them  to  the  action  of  .steam  at  a  temperature  of  100°  C.  to  1.30°  C.  (212° 
to  260°  F.;,  or  by  boiling  them  in  a  one-percent,  aqueous  solution  of  soda. 
For  the  disinfection  of  hospital  wards,  rooms,  etc..  Borabicci  recommends 
nascent  chlorine,  while  a  ten-per-cent.  solution  of  chloride  of  lime  can  be 
used  for  stone  walls,  or,  better,  a  mixture  of  ten  parts  of  chloride  of  lime, 
twenty-five  parts  of  quicklime,  and  one  hundred  of  water.  Fluid  coal  tar  is 
excellent  for  wooden  walls.     Tizzoni  and  Cattani  recommend  a  mixture  of 


§73.]  TRAUMATIC   TETANUS.  359 

one  per  cent,  bichloride  of  mercury,  five  per  cent,  carbolic  acid,  and  five 
tenths  per  cent,  hydrochloric  acid  for  di.sinfccting  the  bands  of  the  suigeon. 
Tetany  after  Extirpation  of  Goitre.— It  is  well  known  that  tetany  may 
follow  total  extirpation  of  the  thyroid  gland.  It  is  characterised  by  a  peculiar 
condition  of  irritation  of  the  anterior  horns  of  the  grey  matter  of  the  spinal 
cord.  The  tonic  spasm,  which  chiefly  affects  the  hands  and  feet,  used  to  be 
thought  to  be  due  either  to  irritation  of  tbe  peripheral  sympathetic  nerves, 
caused,  for  instance,  by  ligation  of  a  great  number  of  ves.sel.s,  or  to  the 
division  of  the  numerous  nerves  of  the  thyroid  gland.  Hoi'sley  and  others 
state  that  tetany  only  occurs  after  total  extirpation  of  the  thyroid,  and  never 
after  a  partial  extirpation  or  removal  of  half  the  gland.  But  Ei.selsberg 
produced  tetany  in  cats  by  removing  four  fifths  of  the  thyroid  ;  tbe  dis- 
ease, however,  was  not  always  fatal,  while  the  tetany  following  total  extir- 
pation was  invariably  so.  Consequently  it  follows  that  the  thyroid  gland 
is  functionally  a  very  important  organ,  and  its  total  removal  will  cause  death. 
Horsley,  Wagner  and  Eiselsberg  consider  that  the  function  of  the  thyroid  is 
to  render  mucoid  substances  innocuous.  After  its  total  extirpation  there 
results  an  accumulation  of  mucin  in  the  tissues  (myxcedema),  and  death  is 
caused  by  mucin  poisoning  with  tetanic  symptoms.  Herbivora,  such  as 
rabbits,  stand  total  extirpation  of  the  thyroid  gland  better  than  carnivora, 
such  as  dogs  or  foxes. 

The  Clinical  Course  of  Tetanus. — The  clinical  picture  presented  by 
tetanus  in  man  is  brieliy  as  follows :  About  the  third  or  fourth  day 
after  infection,  or  still  later,  it  is  noticed  that  the  patient  cannot  open 
his  mouth  properly,  and  complains  of  pain  in  the  muscles  of  mastication. 
At  the  same  time  there  is  usually  a  high  fever,  though  in  the  less  acute 
cases  the  fever  may  be  absent.  As  a  result  of  the  cramp-like  contraction 
of  the  facial  nmscles,  the  .countenance  assumes  a  peculiar  rigidity.  There 
soon  follows  a  certain  amount  of  stiffness  of  the  neck,  with  tetanic  spasms 
lasting  a  few  or  several  minutes,  and  affecting  at  one  time  the  trunk  and 
at  another  the  extremities ;  they  are  very  painful,  and  are  excited  by  the 
slightest  external  irritation — for  example,  by  touching  the  patient,  by  a 
draught  of  air,  a  noise,  etc.  Many  of  the  muscles  become  firmly  and 
permanently  contracted.  Tetanus  does  not  always  begin  with  a  cramp- 
like contraction  of  the  muscles  of  mastication  (trismus).  If  the  patient 
is  carefully  watched,  it  may  be  noticed  that  there  is  at  first  a  peculiar 
stiffness  and  contraction  of  the  muscles  in  the  neighbourhood  of  the 
injury  or  point  of  inoculation,  occurring  perhaps  in  the  upper  or 
lower  extremity,  and  subsequently  tetanus  will  develop  in  the  other 
groups  of  muscles.  These  facts  were  observed  by  Nicolaier  and  Kita- 
sato  in  their  experiments  upon  animals,  which  have  already  been  de- 
scribed. The  fever  in  tetanus  is  usually  high,  the  rise  in  temperature 
not  infrequently  reaching  41°  to  42°  C.  (105-8°  to  107-6°  F.),  or  even 

43°  to  44°  C.  (109-4°  to  111-2°  F.),  while  after  death  there  is  some- 
24 


360  INFLAMMATION   AND   INJURIES. 

times  a  further  rise  to  about  45°  C.  (113°  F.).  This  excessive  increase 
in  body  heat  is  essentially  the  result  of  muscular  contraction,  as  was 
also  proved  by  Leyden's  experiment,  in  which,  within  two  hours,  the 
temperature  of  a  dog  was  made  to  rise  from  39"G°  C.  (103'2°  F.)  to 
44.8°  C.  (112'6°  F.),  simply  from  the  frequently  repeated  muscular 
contraction  caused  by  powerful  electrical  stimulation  of  the  spinal 
cord.  The  patients  usually  retain  perfect  consciousness,  and  are 
bathed  in  sweat.  The  urine  contains  albumen,  probably  as  a  result 
of  the  tetanic  contraction  of  the  renal  arteries.  There  are  also 
cases  which  may  run  a  rapidly  fatal  course  and  yet  be  unaccom- 
panied by  fever.  In  these  there  is  an  extensive  muscular  rigidity, 
particularly  about  the  head  and  trunk,  the  patients  hold  themselves 
perfectly  stiff,  and  there  are  none  of  the  above-described  muscular  con- 
tractions alternating  with  a  momentary  abatement  of  the  rigidity. 

Acute  tetanus  is  usually  fatal.  Death  may  occur  within  twenty- 
four  hours  from  the  beginning  of  the  disease,  or  after  the  lapse  of 
four  to  five  days.  There  is  also  a  subacute  or  chronic  form  of  trisnms 
or  tetanus  which  ordinarily  is  not  accompanied  by  fever.  Sometimes 
the  tetanus  remains  limited  to  the  muscles  in  the  neighbourhood  of  the 
injury,  affecting  perhaps  the  arm  alone,  or  the  injured  leg,  or  the  mus- 
cles of  the  head. 

Head  Tetanus. — Rose,  Bernhardt  and  Giiterbock  state  that  the  so- 
called  head  tetanus  occurs  after  injuries  in  the  region  of  the  distribu- 
tion of  one  of  the  twelve  cranial  nerves.  It  is  distinguished  particu- 
larly by  tetanic  contractions  of  the  muscles  of  mastication — by  trismus, 
as  it  is  called — which  is  combined  with  facial  paralysis  and  spasm  of 
the  muscles  of  the  pharynx,  as  in  hydrophobia,  and  hence  is  sometimes 
given  the  name  of  tetanus  hydrophobicus.  The  paralysis  of  the  facial 
nerve,  according  to  Rose's  view,  is  caused  by  compression  of  the  swoll- 
en nerve  in  the  aqueductus  Fallopii,  but  this  cannot  always  be  demon- 
strated in  the  post-mortem  examination.  Brunner  has  excited  head 
tetanus  in  guinea-pigs  and  rabbits  by  inoculating  into  the  heads  of 
these  animals  a  pure  culture  of  the  bacillus;  and  he  found  that  there 
was  no  paralysis  of  the  affected  half  of  the  face,  but  that  the  asym- 
metry of  the  sides .  of  the  face,  apparently  due  to  facial  paralysis,  was 
really  due  to  tetanic  contracture. 

When  inoculation  was  practised  in  the  median  line,  both  halves  of 
the  face  became  tetanised.  If  the  facial  nerve  was  divided  upon  the 
inoculated  or  diseased  side  of  the  head,  real  paralysis  appeared  for  the 
first  time,  and  the  rigidly  contracted  muscles  became  relaxed.  Brunner 
thinks  that  the  supposed  facial  paralysis  in  head  tetanus,  in  man,  is 
probably  an  error  in  observation,  though  P.  Klemm,  basing  his  opinion 


%7:i]  TRAUMATIC  TETANUS.  361 

upon  an  analysis  of  tliirtj-ei<'lit  publislied  cases,  has  contested  tins  con- 
clusion. Head  tetanus  is  not  always  fatal,  particularly  chronic  cases, 
which  Klenini's  statistics  show  may  last  from  four  to  twelve  weeks,  and 
are  much  more  apt  to  terminate  favourably  than  the  acute  form  of  the 
disease.  Giiterbock  and  Bernhardt  collected  fourteen  cases  with  four 
recoveries.  Klemm  had  one  case  of  chronic  tetanus  hydroj)hol)icus, 
and  collected  the  reports  of  twenty-four  others,  seven  of  which  re- 
covered, six  of  those  lioino;  chronic. 

Pathology  of  Tetanus. — The  anatomical  changes  in  tetanus  are 
slight.  The  microscopical  examination  of  the  s])inal  cord  and  the 
neighbouring  peri])heral  nerves  shows  an  extensive  proliferation  of  the 
cells.  Monastyrski  found  half-moon-shaped  extravasations  of  blood  in 
the  interstitial  connective  tissue  of  the  spinal  cord  and  peripheral 
nerves,  and  a  granular  infiltration  of  the  nerve  cells. 

Prognosis  of  Tetanus. — The  prognosis  of  tetanus,  as  may  be  gath- 
ered from  what  has  been  said  above,  is  for  the  most  part  unfavour- 
able. Acute  tetanus  generall}^  terminates  fatally,  while  the  subacute 
and  the  rare  chronic  forms  of  the  disease  have  a  more  favourable 
prognosis.  In  those  cases  in  which'  the  tetanus  is  confined  to  the  mus- 
cles of  one  limb,  or  to  the  head  (tetanus  hydrophobicus),  the  disease 
does  not  always  terminate  fatally. 

Treatment  of  Tetanus. — Treatment  in  acute  tetanus  has  little  effect. 
In  the  first  place,  the  injury  or  wound  should  always  receive  proper 
surgical  treatment  according  to  antiseptic  rules.  It  is  very  important 
that  every  wound  which  has  become  soiled  with  earth,  or  similar  sub- 
stances, should  be  thoroughly  cleaned  and  disinfected  as  soon  as  possible. 
Tizzoni  and  Cattani  recommend,  for  the  disinfection  of  Avounds  in 
which  there  is  fear  of  the  development  of  tetanus,  a  one-per-cent.  solu- 
tion of  nitrate  of  silver,  which  destroys  the  bacilli  and  the  spores  very 
rapidl}"  and  certainly — in  one  minute.  If  tetanus  already  exists  when 
the  case  comes  under  observation,  we  are,  as  a  general  thing,  poM'erless 
to  hold  it  in  check,  and  almost  all  the  patients  die  after  a  very  short 
time.  Very  rarely,  and  then  only  when  the  case  is  seen  immediately 
after  the  reception  of  the  injury,  can  tetanus  be  checked  by  burning 
the  wound  with  the  tliermo-cautery.  Recovery  may  often  be  obtained 
by  amputating  the  injured  limb,  though  even  this  is  sometimes  unsuc- 
cessful. Especially  in  tetanus  following  injuries  of  the  extremities, 
attempts  have  been  made  to  arrest  the  disease  by  exposing  and  stretch- 
ing the  principal  nerve  trunks — the  sciatic,  for  instance — which  supply 
the  injured  portion  of  the  body,  and  Verneuil,  Kocher  and  others  have 
reported  cures  by  this  treatment.  The  good  obtained  from  nerve- 
stretching  in  infectious  tetanus  is  certainly  open  to  doubt  (§  97). 


'V 


362  INFLAMMATION  AND   INJURIES. 

The  remainder  of  the  treatment  for  tetanus  is  purely  symptomatic. 
Subcutaneous  injections  of  morphine  are  often  used,  accompanied  by 
the  administration  of  chloral  hydrate  (three  to  five  granimes  pro 
die)  by  the  rectum,  or  large  doses  of  chloral  hydrate  or  bromide  of 
potassium  may  be  given  internally,  two  grammes  of  chloral  hydrate 
being  alternated  with  the  same  amount  of  bromide  of  potassium  every 
two  hours.  Kane  states  that,  of  two  hundred  and  twenty-eight  cases 
treated  with  chloral  hydrate,  one  hundred  and  thirty-four  recovered 
and  ninety-four  died.  Of  ninety-three  treated  with  chloral  hydrate  in 
combination  wich  other  remedies,  thirty-three  died.  The  most  efficient 
means  for  quieting  a  patient  during  a  paroxysm  is  to  administer  chjoro- 
form  by  inhalation  ;  but  after  the  cessation  of  the  narcosis  the  muscular 
spasm  immediately  recurs.  Curare,  the  Indian  arrow  poison,  which 
has  the  power  of  paralysing  voluntary  muscles,  is  an  exceedingly 
valuable  remedy,  though  very  inconstant  in  its  effects  on  account  of  its 
variable  chemical  composition.  The  success  of  the  curare  treatment 
has  not,  however,  been  very  encouraging.  Its  concentration  varies 
within  wide  limits.  Curare  can  be  injected  in  the  dose  of  about  0'015  to 
0*05  grammes  every  quarter  to  half  to  one  hour,  Karg  has  curarised 
patients  (by  subcutaneous  injection)  till  respiration  became  paralysed, 
after  previously  performing  a  prophylactic  tracheotomy  for  facilitating 
artificial  respiration  ;  but  all  the  cases  treated  in  this  way  terminated 
fatally.  It  is  a  better  plan  to  combine  the  administration  of  narcotics 
with  injections  of  curare.  Bacelli  has  obtained  satisfactory  results  by 
injections  of  carbolic  acid  (0*01  gramme  every  hour).  Sormani  recom- 
mends iodoform.  According  to  the  latter's  experiments,  the  tetanus 
poison  is  neutralised  by  iodoform,  or  by  the  iodine  derived  from  it ; 
and  by  treating  the  wound  with  iodoform  during  the  period  of  its  in- 
cubation tetanus  can  be  prevented.  He  states  that  mice  inoculated 
simply  with  earth  died  of  tetanus  in  less  than  three  days ;  but  if  the 
earth  used  in  the  inoculations  was  first  mixed  with  iodoform  the 
animals  remained  unafiected  by  the  disease.  Pure  cultures  are  not 
changed  when  iodoform  is  added  to  them,  but  are  killed  in  one  minute 
by  the  addition  of  a  one-per-cent.  solution  of  nitrate  of  silver  (Tizzoni, 
Cattani),  Sormani  also  recommends  iodol  and  a  two-per-cent.  acid 
solution  of  bichloride  of  mercury,  or  chloral  with  camphor.  The 
further  treatment  of  the  disease  consists  in  careful  isolation  of  the 
patient,  and  in  keeping  away  from  him  every  sort  of  external  irritation 
or  disturbance,  particularly  during  the  stage  when  the  muscular  spasms 
are  a  prominent  symptom. 

De  Renzi  has  succeeded  in  curing  four  out  of  a  total  of  five  cases 
of  tetanus  by  securing  to  the  patient  absolute  rest,  which  is  the  very 


g74.]  SEPTlCililMIA.  363 

best  curative  agent  at  our  disposal.  De  Renzi  places  the  patient  with 
tetanus — the  ears  having  been  plui^ged — in  a  room  wliich  is  completely 
isolated,  absolutely  quiet,  and  without  windows.  All  the  necessary 
manipulations  in  the  care  of  the  patient  are  performed,  as  far  as  pos- 
sible, in  the  dark.  The  nourishment  is  entirely  fluid.  AVhen  the  pain 
is  severe  De  Renzi  gives  belladonna  and  ergot  internally. 

Value  of  "Curative  Serum"  {Antitoxine). — It  has  been  mentioned 
before  that  Behriug,  Tizzoni,  and  Cattani  have  prepared  and  recom- 
mended a  curative  serum  (antitoxine)  for  treating  tetanus  in  man.  It 
is  made  from  the  blood  serum  of  dogs,  less  often  of  rabbits  which  have 
been  rendered  immune  from  the  disease,  and  when  injected  subcutane- 
ously  in  man  is  said  to  have  cured  a  number  of  cases  of  tetanus  :  but 
as  yet  it  is  impossible  to  come  to  any  definite  conclusion  upon  the  the- 
rapeutic value  of  this  serum. 

§  74.  Septicsemia. — The  term  septiccemia  is  given  to  a  poisoning  of 
the  body  (intoxication)  which,  as  a  rule,  rapidly  terminates  in  death, 
and  is  not  characterised  by  the  formation  of  such  metastatic  suppura- 
tive processes  as  occur  in  the  disease  called  pyaemia  (pus  poisoning), 
which  is  closely  related  to  it.  Septicseraia  is  usually  found  in  conjunc- 
tion with  putrefactive  (gangrenous)  changes  in  a  wound  or  inflamma- 
tory focus,  though  it  may  sometimes  have  an  intestinal  or  pulmonary 
origin.  It  is  often  perfectly  impossible  to  make  a  sharp  distinction  be- 
tween pyaemia  and  sepsis,  as  the  two  diseases  are  frequently  found  in 
combination,  both  clinically  and  anatomically,  and  hence  the  term  sep- 
ticopyemia. 

Cryptogenetic  Septicaemia. — Oftentimes  the  point  at  which  the  infec-  ^/-  , 
tion  gains  access  to  the  system  cannot  be  found,  and  we  then  speak  of 
a  cryptogenetic  septicaemia. 

Etiology  of  Septicaemia  in  Man.— Virchow,  Billroth  and  others  produced 
septicaemia  by  injecting  decomposing  substances  into  the  vascular  system 
and  tissues  of  animals,  and  the  discoveries  in  fermentation  and  decomposi-  ' 
tion  which  were  made  about  the  same  time  helped  to  shed  light  upon  the 
importance  of  lower  organisms  in  the  production  of  sepsis.  Then  Panum 
demonstrated  that  analogous  septic  diseases  could  be  excited  by  using  de- 
composing fluids  which  had  been  boiled  after  the  fungi  existing  in  them 
were  removed.  This  theory  of  the  origin  of  septicaemia,  partly  from  bacteria 
and  partly  from  fluids  free  of  bacteria,  is  now  being  still  fm*ther  elaborated, 
so  that  at  present  we  distinguish  two  principal  forms  of  septicaemia,  one 
caused  by  fungi  and  the  other  by  soluble  chemical  poisons.  The  septicaemia 
due  to  the  presence  of  bacteria  is  an  infectious  disease  capable  of  transmis- 
sion to  other  animals  ;  in  other  words,  the  blood  of  animals  having  this  kind 
of  sepsis  will  produce  the  same  disease  when  inoculated  into  healthy  animals. 
The  virulence  of  the  blood  increases  each  time  it  is  taken  from  an  animal 
having  the  disease  and  inoculated  into  a  healthy  one — that  is,  its  virulence 


364  INFLAMMATION   AND  INJURIES. 

bears  a  direct  proportion  to  the  frequency  of  its  transmission  from  one 
animal  to  another. 

In  the  second  form  of  septicaemia,  the  blood  contains  dissolved  in  it 
chemical  poisons  or  gases,  the  poisonous  products  of  the  metabolism  of  the 
fungi,  and  it  is  not  infectious  any  more  than  the  blood  of  an  individual  suf- 
fering from  strychnine  or  prussic-acid  poisoning. 

Between  the  two  forms  of  septicaemia,  the  one  due  to  toxines  and  the 
other  to  bacteria,  there  are  numerous  transition  and  combined  forms  ;  in 
other  words,  bacteria  of  every  description  are  sometimes  found  in  the  blood 
of  those  suffering  from  poisoning  by  the  chemical  products  of  bacterial 
metabolism. 

The  changes  which  take  place  in  decomposition  are  of  great  importance 
for  an  undei*standing  of  the  etiology  of  septicaemia.  It  has  been  mentioned 
that  in  the  decomposition  excited,  in  albuminous  bodies  by  bacteria,  various 
substances  are  formed,  the  chief  of  which  are  peptones  and  similar  bodies, 
nitrogenous  bases  (leucine,  tyrosine,  amine),  organic  fatty  acids,  aromatic 
products,  colouring  matters,  and  particularly  poisonous  toxalbumens,  and 
certain  alkaloids  to  which  have  been  given  the  name  of  cadaver  alkaloids  or 
ptomaines.  The  latter  possess  intensely  poisonous  properties.  It  had  long 
been  known  that  toxic  bodies  were  present  in  the  products  of  decomposition, 
as  Panimi,  in  1863,  had  isolated  from  putrefying  substances  his  putrid  poison. 
Bergmann  and  Schmiedeberg  obtained  a  crystalline  body,  sepsine,  Billroth 
discovered  another,  etc.  Selmi  was  the  first  to  recognise  the  nature  of  these 
bodies,  and  he  gave  them  the  name  of  cadaver  alkaloids  or  ptomaines. 
Brieger  and  others  have  obtained  several  ptomaines  in  a  pure  state,  such  as 
collidine,  peptoxine,  neurine,  neuridine,  choline,  etc.,  and  have  investigated 
their  action  upon  animals. 

Paterno,  Spica  and  others  found  that  ptomaines  are  also  a  product  of 
normal  metabolism,  though,  of  course,  they  are  formed  in  small  amounts. 
Bergmann  and  Angerer  have  proved  that  febrile  diseases  similar  to  septicae- 
mia can  be  produced  by  non-bacterial  poisons  such  as  ferments.  In  a  case  of 
septic  (putrefactive)  intoxication  occurring  without  the  presence  of  micro- 
organisms in  the  blood,  there  will  somewhere  be  found  a  focus  of  suppnra- 
tion  or  some  decomposing  pus  or  blood,  the  decomposition  being  due  to 
micro-organisms,  particularly  the  various  kinds  of  bacilli.  If  the  focus  of 
suppuration  is  removed  early  enough  recovery  maj"  take  place.  In  these 
foci  of  suppuration  or  gangrene  there  will  be  not  only  the  bacteria  of  decom- 
position, but  many  others,  such  as  pyogenic  staphylococci,  streptococci,  and 
different  bacilli. 

Septicemia  in  man  is  caused  sometimes  by  bacilli  and  sometimes  by  cocci 
(streptococcus  pyogenes,  streptococcus  septicus  Fliigge,  staphylococcus  aure- 
us). Ogston  and  Rosenbach  identified  the  streptococcus  pyogenes  as  the 
cause  of  the  septicaemia  in  a  case  of  progressive  gangrenous  phlegmon  which 
produced  fatal  sepsis.  In  the  septicaemia  following  progressive  gangrenous 
emphysema,  Rosenbach  and  others  found  the  very  bacillus  which  Koch 
proved  to  be  the  cause  of  malignant  oedema — a  disease  running  a  rapidly  fatal 
course  in  mice,  guinea-pigs,  and  rabbits. 

These  oedema  bacilli  (Fig.  270),  which  Pasteur  formei'ly  designated  as 
vibrions  septiques,  are  morphologically  similar  to  the  anthrax  bacilli  (Figs. 


§:4.] 


SEPTICEMIA. 


365 


K 


261,  265).  It  is  interesting  to  note  that  the  symptomatic  anthrax  occur- 
ring endemic-ally  in  cattle  is  produced  by  siniihir  bacilli,  and  that  their 
multiplication  in  the  subcutaneous  cellular 
tissue  causes  inflammatory  swelling  with  the 
evolution  of  gas.  Furthermore,  in  haemor- 
rliagic  septicemia  many  kinds  of  bacilli  have 
been  fovnid.  Lubai'sch  observed  a  case  of 
septic  pneumonia  in  a  newborn  child  which 
died  two  days  after  birth. 

Experimental  Septicaemia  in  Animals.— 
Thanks  to  Robert  Koch,  we  po.ssess  a  more 
accurate  knowledge  of  liunian  septicaemia  on 
account  of  this  investigator's  experiments 
upon  animals.  There  is  a  toxic  septicaemia 
(septic  intoxication),  and  a  septicaemia  which  is  bacterial  in  its  nature  (trans- 
missible septic  infection).  Toxic  septicsemia  occurs  after  the  injection  of  large 
amounts  of  decomposing  substances  into  the  subcutaneous  cellular  tissues. 
Immediately,  or  soon  after  the  injection,  there  ensue  restlessness,  weakness, 
cramps,  often  vomiting,  finally  paj-alysis,  and  not  infrequently  death  fol- 
lows in  a  few  houi'S  from  paralysis  of  respiration.  No  bacteria  are  found  in 
the  blood  or  internal  organs.  If  decomposing  fluids,  with  the  bacteria  of  de- 
composition, are  kept  for  twenty-four  hours  in  the  incubator  at  a  temperature 
of  40="  to  41°  C.  (104°  to  105-8°  F.)  and  then  used  for  injection,  the  poisonous 
effects  are  very  pronounced  ;  but  if  the  fluid  is  ti'eated  in.  the  same  way  for 
forty-eight  hours,  no  effects  follow  its  injection. 


I 
// 

A  B 

Fig.  270. — Bacillus  of  nialijfnant  oede- 
iiia(vibrionscptique  Pa-steur):  .4, 
from  the  spleen  of  a  guinea-pig; 
B,  from  the  lung  of  a  mouse 
(Koeli). 


U^'^*^^^-^^ 


Fig.  271. — Bacilli  of  septicaemia  in  a  vein  of  the  diaphragm,  taken  from  a  septicaemic  mouse. 
White  blood-corpuscles,  some  containin<r  bacilli,  and  some  chantred  into  ma-sses  of  bacilli. 
X  700  (Koch). 

In  the  bacterial  septicaemic  infection  great  numbers  of  bacteria  will  be 
found  in  both  the  blood  and  the  tissues.  Koch  showed  that  there  were  two 
kinds  of  bacterial  septicaemia  :  the  septicaemia  of  mice  and  the  septicaemia  of 
rabbits,  both  of  which  are  caused  by  bacilli.  The  bacilli  of  mouse  septicae- 
mia are  very  fine  rods  (Figs.  271,  273),  like  the  bacilli  of  swine  erysipelas  ; 
whilst  the  bacilli  of  rabbit  septicaemia,  recently  described  by  Gaifky,  are 
identical  with  or  closely  related  to  the  bacteria  of  chicken  cholera,  the  bacilli 


366 


INFLAMMATION   AND    INJURIES. 


Fig.  272. — Blood  from  a 
septicsemic  mouse, 
dried  ou  a  cover  glass, 
stained  with  metliyl 
violet,  and  laid  in 
Canada  balsam.  Eed 
blood-corpuscles  and 


small  bacilli. 
(Kochj. 


700 


of  swine  fever,  and  the  bacilli  of  duck  cholera.  Hueppe  proposes  to  call 
these  micro-organisms  the  bacteria  of  septicaemia  hasmorrhagica.  There 
are,  of  course,  poisonous  metabolic  products  developed  in  these  bacterial 
septicaemiae,  and  Hotfa  has  isolated  from  tbe  animals  suffering  from  rabbit 
septicaemia  a  poisonous  base,  methylguanidin  (CaHTNaj,  probably  pro- 
duced by  the  oxidation  of  creatin.  Animals  are  also 
afflicted  with  cocci-septicaemiae.  To  this  class  belongs 
Fraukel's  coccus  of  sputum  septicemia,  which,  when 
the  saliva  from  the  humau  mouth  is  injected  into  rab- 
bits, is  the  exciting  cause  in  these  animals  of  septicae- 
mia. This  same  coccus  is  in  all  probability  the  excitant 
of  croupous  pneumonia  in  man.  The  streptococcus 
septicus  and  a  coccus  found  by  Nicolaier  in  foul  earth 
are  precisely  similar  to  the  streptococcus  pyogenes,  as 
is  also  the  micrococcus  tetragonus.  Severe  septicemia 
is  occasionally  transmitted  fi'om  parrots  to  man.  Le- 
petit  found  as  its  cause  a  small  coccus  which  he  ob- 
tained from  the  blood  and  made  pure  cultures  of.  He 
found  the  staphylococcus  aureus  and  citreus  in  the 
lungs. 

Bacteria  of  Decomposition.— Hauser  has  taught  us 
the  morphology  and  biology  of  three  kinds  of  bacteria 
causing  decomposition,  and  called  by  him  proteus  vul- 
garis, proteus  mirabilis,  and  proteus  Zenkeri.  From 
small  rods  sim^ilar  to  Cohn's  bacterium  termo  there 
develop  in  proper  nutritive  media  longer  rods  and 
screw-shaped  filaments,  which,  after  exhausting  the 
nutritive  medium,  change  into  short  rods  and  sphe- 
rules, which  are  probablj-  spores.  These  three  kinds  of 
bacteria,  isolated  from  decomposing  substances,  are 
capable  of  exciting  decomposition,  while  the  filtrate 
freed  from  bacteria  did  not  have  this  power  (saprogen- 
ic). The  investigations  about  their  pathogenic  properties  and  their  relation- 
ship to  septicaemia  revealed  the  fact  that  these  three  bacteria  evolved,  by  ex- 
citing decomposition  of  animal  tissue,  a  violent  chemical  poison,  which,  when 
introduced  in  very  small  amounts  into  the  blood  and  lymphatic  vessels  of 
small  animals,  caused  the  death  of  the  latter  with  every  symptom  of  putrid 
intoxication.  These  bacteria,  which  are  saprophytic,  are  not  tliemselves 
pathogenic— that  is,  they  are  not  capable  of  developing  within  the  living  body. 
Rosenbach  has  cultivated  three  kinds  of  saprogenic  bacteria,  two  of  which 
are  toxic. 

Ferment  Intoxication  and  Septicaemia.— Semmer,  Eossbach  and  Eosen- 
berger  have  made  experiments  which  show  that  after  the  injection  of  fer- 
ments or  sterilised  septic  blood  the  animals  thus  treated  will  die  of  sepsis, 
from  the  development  of  bacteria  in  the  blood.  If  these  experiments  are 
free  from  error,  it  seems  to  prove  that  the  properties  of  the  blood  are  so 
changed  by  the  injection  of  the  above-named  substances  that  it  is  rendered 
possible  for  bacteria  to  develop  in  it— a  thing  which  would  be  impossible  if 
normal  conditions  existed  in  the  blood  and  tissues.    But  there  is  some  reason. 


Fig. 


273.— White  blood- 
corpuscles  from  a 
vein  in  the  dia- 
phragm of  a  septicae- 
mic  mouse.  This 
shows  how  the  cor- 
puscles become  crrad- 
ually  chanjred  into  a 
mass  of  bacilli,  x  700 
(Koch). 


§  74.]  SEPTICAEMIA.  367 

to  doubt  that  the  substances  injected  in  these  experiments  were  actually  free 
from  all  contjimination  by  bacteria.  Bergmaiin  and  Angerer  have  made 
some  interesting-  discoveries  as  to  the  relationship  of  ferment  intoxication  to 
septicaemia.  It  is  well  known  that  Birk  and  others,  by  transfusing  blood  con- 
taining ferment,  or  by  injecting  fibrin  ferment  into  tlie  blood,  obtained  in  the 
animals  experimented  upon,  both  during  life  and  after  death,  the  same  phe- 
nomena which  occur  after  the  introduction  of  fluids  which  are  decomposing 
or  rendered  foul  by  bacterial  vegetation.  The  changes  con.sist  essentially  in  a 
more  or  less  extensive  disintegi-ation  of  the  white  blood-corpu.scles,  with  a  sec- 
ondary formation  of  fibrin  in  the  capillaries,  the  large  pulmonary  vessels,  and 
in  the  heart.  Bergman n  and  Angerer  excited  the  same  changes  by  injecting 
large  doses  of  sterilised,  transparent,  aqueous  solutions  of  pepsin  and  pancre- 
atin.  The  severe  ferment  intoxications  run  a  rapidly  fatal  coui-se,  presenting 
the  picture  of  intoxication  by  decomposing  substances.  The  pure  ferment 
consequently  acts  in  a  manner  similar  to  the  pathogenic  bacteria — that  is, 
mainly  by  destroying  the  white  blood-corpuscles.  These  investigators  were 
unable  to  confirm  the  above-mentioned  statements  of  Ro.senberger  and  Ross- 
bach,  that  bacteria  can  develop  as  a  result  of  the  presence  of  sterilised  fer- 
ment solutions  in  the  blood. 

Occurrence  of  Septicaemia.— Septicaemia  in  man,  since  the  antiseptic 
method  of  treating  wounds  has  come  into  general  use,  is  of  much  less 
frequent  occurrence  than  was  formerly  the  case.  Antisepsis,  carefully 
carried  out  in  every  operation  and  in  the  subsequent  treatment  of  every 
wound,  is  the  best  guarantee  against  the  occurrence  of  septicaemia.  If 
septicaemia  should  make  its  appearance  after  an  operation  upon  healthy 
tissue,  it  is  a  proof  that  there  has  somewhere  been  a  transgression  of 
the  rules  of  asepsis.  The  septic  poison,  the  micro-organisms,  may  gain 
access  to  the  wound  in  many  different  ways — for  instance,  at  the  time 
the  injury  was  received,  or  by  infected  instruments,  unclean  fingers,  etc. 

Pathological  Changes  in  Septicaemia. — The  pathological  changes  in 
septicicuiia  con.-i>t.  in  the  first  place,  in  the  local  changes  at  the  point 
of  infection  and  the  surrounding  parts,  which  will  be  more  minutely 
described  when  we  come  to  the  symptomatology.  The  most  constant 
change  is  found  in  the  blood  after  death.  It  is  dark-coloured,  like  tar, 
prone  to  rapid  decomposition,  and  not  infrequently  has  an  acid  reac- 
tion (carbonate  of  ammonia).  The  above-mentioned  micro-organisms 
will  be  found  in  the  vessels  and  blood,  and  in  the  tissues  of  the  differ- 
ent organs,  though  in  cases  of  pure  intoxication  the  micro-oi-ganisms 
will  not  have  a  general  distribution  throughout  the  body,  but  will  be 
present  only  in  the  focus  of  infection.  The  disintegration  of  the  white 
and^to  a  less  extent,  of  the  red  blood-corpuscles,  brought  about  by  the 
micro-organisms  or  by  the  products  of  their  metabolism,  is  character- 
istic. The  bacteria  are  present  in  the  white  blood-corpuscles,  in  which 
they  are  scattered  through  the  system,  and  finally  change  the  leucocytes 


368  INFLAMMATION   AND   INJURIES. 

into  masses  of  bacteria  (Figs.  271,  273).  As  a  result  of  tlie  disintegra- 
tion of  the  white  blood-corpuscles,  the  blood  possesses  an  increased 
power-  of  coagulation.  In  consequence  of  the  changes  in  the  composi- 
tion of  the  blood  and  the  alterations  in  the  walls  of  the  vessels,  allow- 
ing their  contents  to  escape  through  them,  there  arises  a  tendency  to 
small  and  large  hsemorrhages  in  the  gastro-intestinal  tract,  in  the  mes- 
entery and  omentum,  in  the  spleen,  endocardium,  pleura,  kidneys,  blad- 
der, and,  in  short,  in  all  the  different  organs.  The  changes  occurring 
in  the  heart  and  lungs  are  not  constant,  there  being  sometimes  a  gen- 
eral pleurisy,  and  sometimes  symptoms  of  pericarditis.  In  the  intesti- 
nal canal  there  is  frequently  an  extensive  enteritis,  taking  the  form  of  a 
catarrhal  swelling  with  ecchymoses,  and  the  formation  of  ulcers,  as  in 
a  dysenteric  inflammation.  The  spleen  is  almost  always  large  and  soft, 
and  the  liver  is  likewise  somewhat  enlarged,  congested,  and  friable.  The 
kidne_ys  are  increased  in  size,  the  parenchyma  is  in  the  stage  of  cloudy 
swelling,  and  there  is  a  catarrhal  change  in  the  uriniferous  tubules. 
The  above-mentioned  micro-organisms  will  be  found  most  abundantly 
in  the  kidneys,  and  chiefly  in  the  capillaries  of  the  glomeruli  and  in  the 
afferent  vessels.  The  changes  in  the  internal  organs  are  sometimes  very 
slight.  Diffuse  metastatic  inflannnations,  embolic  infarcts  and  foul 
abscesses  also  occur  in  septicaemia,  especially  when  the  latter  is  com- 
bined with  pyaemia  (pyo-septicsemia) ;  but  they  are  by  no  means  so  fre- 
quent or  so  characteristic  of  septicaemia  as  are  the  metastatic  suppura- 
tions for  pyaemia..! 

The  Clinical  Course  of  Septicaemia. — The  /symjjtoms  of  sejiticaemia 
are,  for  the  most  jmrt,  characterised  by  the  presence  of  a  high  and  gen- 
erally continuous  fever,  and  by  a  number  of  inflammatory  ])rocesses. 
The  two  different  forms  of  se])ticnemia — distinguished  in  respect  to  their 
etiology,  the  j^utrid  or  septic  intoxication,  due  to  the  products  of  bac- 
terial metabolism,  and  that  due  to  the  presence  of  bacteria — cannot  clin- 
ically be  sharply  differentiated,  and  in  man,  as  we  have  stated  before, 
they  not  infrequently  occur  in  combination.  It  is  im])ossible  to  de- 
scribe the  symptoms  of  septicaemia  so  as  to  include  all  its  forms. 

The  wounds  which  are  capable  of  giving  rise  to  septicaemia  may  be 
fresh  or  granulating.  Every  wound,  no  matter  how  small,  can  be  the 
starting-point  for  septic  infection.  It  was  formerly  believed,  from 
Billroth's  experiments,  that  healthy  granulations  were  imj^crmeable 
for  decomposing  fluids  and  for  micro-organisms,  but  Maas  and  Hack 
proved  that  this  view  was  not  correct.  The  local  manifestations  at  the 
point  of  the  injury  vary  greatly,  and  they  may,  in  fact,  be  entirely 
absent,  as  in  the  cases  of  septicaemia  which  run  a  very  acute  course. 
These  are  characterised  by  a  rapid  febrile  intoxication  of  the  whole 


§74.] 


SEPTICAEMIA. 


369 


system,  which  occurs  before  there  are  any  local  symptoms  in  the 
wound.  In  the  worst  cases  there  is  a  gradual  clouding  of  the  mind, 
followed  by  stupor  and  death,  within  the  iirst  two  or  three  days. 

TIu>    fchrilf    iiiovL'inciit    is    not   characteristic   in    septicaeniia;    in 
fact,  there  are  forms  of  the  disease  which  run  their  course  without 


Puis 

Tago: 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11     1 

180 
170 
160 
l.W 
ttO 
130 
120 
110 
100 

90 

80 
70 

f 

a 

r 

a. 

r 

a 

/' 

a. 

r 

CL 

/• 

a 

f\cL 

/' 

a 

r 

u 

f 

a 

f 

a 

41,5 

41,0 

.^.  40,5 

40,0 

39,5 

39,0 
38,5 
38,0 
37,5 
37,0 
36,5 

+ 

/•• 

.•■ 

/ 

A 

\ 

^ 

J\ 

1 

V 

■ 

A 

l\ 

/ 

A 

// 

/i 

}:..■• 

\y 

'    \ 

\/ 

^ 

// 

h 

// 

V 

V 

\ 

/ 

/ 

^ 

\ 

/: 

t 

JL 

2_ 

FiQ.  274. — Temperature  curves  in  septicEemia:  1,  temperature  curve  in  septicspmia,  with  high 
fever;  death  with  a  temperature  of  41°  C.  (105.6  F.),  and  pulse  of  170  on  the  3rd  day  after 
the  operation  (Laparatomy);  2,  temperature  curve  in  septiceemia  with  a  slight  rise  of  tem- 
perature ;  death  on  the  4th  day  after  the  injury  (gun-shot  w^ound),  preceded  by  a  subnor- 
mal sinking  temperature  and  very  rapid  pulse. 

any  fever  at  all.  On  the  other  hand,  the  frequency  of  the  pulse 
is  always  noticeably  increased  (Fig.  274).  If  the  ordinary  wound- 
fever,  occurring  after  open  injuries  from  the  absorption  of  the  prod- 
ucts of  decomposition,  is  looked  upon  as  a  septic  intoxication,  it  must 
be  admitted  that  we  frequently  meet  with  transient  abortive  forms  of 
septic  intoxication,  which  are  marked  by  a  moderate  rise  of  tempera- 
ture to  about  39°  C.  (102-2°  F.),  and  terminate  favourably  in  a  few 
days  without  giving  rise  to  any  appreciable  complication  in  the  wound 
or  in  the  internal  organs.  This  simple  septic  fever  is  of  very  common 
occurrence,  while  it  is  relatively  seldom  that  we  meet  with  the  above- 
mentioned  severe  cases  of  septic  intoxication  which  run  a  rapidly  fatal 
course.  In  discussing  fever  in  general,  we  learned  that  the  latter  may 
be  caused  by  the  absorption  of  substances  which  were  not  decomposed, 
such  as  fibrin  ferment,  etc. — a  condition  which  Yolkmann  and  Genzmer 
have  designated  as  wound-fever.  Consequently  our  present  knowledge 
of  the  etiology  of  fever  makes  it  impermissible  to  look  upon  every  rise 
in  temperature  in  those  who  have  been  injured  as  a  septic  fever. 

All  cases  of  general  sepsis  in  which  the  inflammation  is  plainly 
spreading  from  the  point  of  infection  have,  in  general,  an  unfavourable 


Y.S. 


370  INFLAMMATION   AND  INJURIES. 

prognosis.     The  severity  of  tlie  constitutional  symptoms  and  the  ex- 
tent of  the  local  inflammatory  process  vary  here,  too,  very  much,  the 
latter  showing  all  the  steps  from  a  mild  lymphangitis  to  a  violent  sep- 
tic phlegmon  or  an  acute  septic  gangrene.     In  this  class  belong  the 
cases  of  septic  infection  which  arise  from  very  slight  injuries,  such  as 
are  not  uncommon  on  the  fingers  of  surgeons  after  operations  upon  ab- 
scesses, decomposing  tissue,  etc.,  from  infection  by  putrefying  matter. 
After  twelve  to  twenty-four  hours  there  is  a  chill,  and  the  temperature 
rapidly  rises  to  39-5°  C.  (103-1°  F.)  or  40°  C.  (104°  F.)  and  higher,  the 
small  wound  on  the  finger  becomes  painful  and  is  inflamed,  the  epitroch- 
lear  and  axillary  glands  swell,  and  red  streaks  appear  on  the  arm  (septic 
lymphangitis).     By  the  next  day,  if  proper  treatment  is  employed,  the 
septic  infection  may  have  run  its  course,  or  recovery  may  take  place 
with  the  formation  of  pus  at  the  point  where  the  injury  was  received, 
and  with  the  development  of  circumscribed  abscesses  in  the  epitrochlear 
and  axillary  glands,  or  death  may  follow  from  general  septic  poisoning. 
'In  other  instances,  the  septic  inflammation  starting  from  the  wound  is 
severe,  and  leads  to  an  extensive,  rapidly  spreading  cellulitis,  which  is 
accompanied  by  high  fever,  as  described  on  page  336.     Earely,  and 
then  particularly  after  severe  traumatisms,  such  as  a  "  run-over  "  acci- 
dent, a  rapidly  advancing,  putrefactive  inflammation  will  develop  with 
the  evolution  of  gas  in  the  tissues,  usually  terminating  in  death  within 
the  first  forty-eight  hours.     The  gangrene  of  the  tissues  in  such  cases 
may  in  the  first  place  be  caused  by  the  injury  alone,  and  then,  in  addi- 
tion to  the  local  traumatic  gangrene,  there  is  added  a  rapidly  extending 
decomposition,  due  to  the  entrance  of  the  germs  of  decomposition, 
which  may  spread,  and  involve  the  entire  extremity.     Sometimes  this 
traumatic  origin  of  the  gangrene  due  to  contusion  of  the  tissues  can  be 
excluded,  and  yet  there  will  be  a  rapidly  spreading  gangrene,  with  de- 
composition and  the  evolution  of  gas.     This  is  sometimes  the  case  in 
snake  bites.     The  acute  purulent  oedema  of  Pirogoff  and  the  gangrene 
foudroyante  of  Maisonneuve  belong  to  those  worst  forms  of  septic  in- 
flammation.    The   affected   extremity  is   usually  excessively  swollen, 
partly  from  oedema  and  partly  from  the  gases  produced  by  decomposi- 
tion.'   At  the  same  time  there  is  given  off  a  foul  odour,  and  a  crackling 
emphysema  of  the  skin  radiates  in  all  directions  from  the  wound.     The 
muscles  become  changed  into  a  reddish  bi-own  mass  full  of  bubbles  of 
gas.     Coma  and  death  follow  in  a  few  days,  usually  preceded  by  an  in- 
crease in  the  oedema.     This  progressive  gangrenous  emphysema  (gan- 
grene gazeuse),  which,  by  the  way,  is  of  very  infrequent  occurrence 
since  the  introduction  of  antiseptic  methods,  is  caused  by  bacilli  similar 
to  those  which  Koch  identified  as  the  cause  of  malignant  osdema  in 


§74.]  SEPTICiI^]MIA.  37 1 

mice,  gninca-pi'c^s,  and  ral)l)its.  Progrossivc  f^angrenoiis  empliyseina 
occurs  in  conjunction  with  compound  fj-acturcs,  or  any  deep  wound 
into  which  earth  or  some  other  material  containing  the  cedema  bacilh 
lias  penetrated. 

The  other  symptoms  of  septicaemia  referable  to  the  internal  organs 
are  caused  by  the  general  septic  infection.  Usually  the  spleen  is 
plainly  enlarged,  and  very  often  the  liver  also.  Not  infrequently 
there  is' jaundice,  generally  of  a  hematogenous  nature,  as  a  result  of 
the  disintegration  of  the  red  blood-corpuscles  caused  by  the  micro- 
organisms or  their  products.  There  are  usually  gastro-intestinal  dis- 
turbances, which  in  the  severer  forms  of  septicaemia  give  rise  to  a 
diarrhoea  which  is  sometimes  faeculent,  sometimes  mucous,  or  even 
bloody-diphtheritic  in  character. 

'The  urine  ordinarily  contains  albumen.  The  diffuse  inflammations 
of  the  pleura,  the  pericardium  and  endocardium  give  rise  to  marked 
symptoms  only  in  exceptional  cases.  There  are  not  infrequently  ex- 
anthematous  eruptions  of  the  skin,  which  take  the  form  of  blebs  or 
pustules,  or  resemble  urticaria,  measles,  or  scarlet  fever.  Veins  and 
arteries  may  be  opened  by  decomposing  abscesses,  leading  to  dangerous 
haemorrhages. 

Prognosis  of  Septicaemia. — The  prognosis  of  septicsemia  is,  in  the 
pronounced  cases  of  microbe-septicaemia,  for  the  most  part  unfavour- 
able. The  cases  of  intoxication  by  decomposing  substances  in  which, 
by  proper  treatment,  we  can  remove  from  the  body  the  focus  of  infec- 
tion, have  relatively  the  best  prognosis.  After  this  procedure  has 
been  accomplished  the  absorption  of  the  products  of  bacterial  meta- 
bolism ceases,  and  with  it  also  the  poisoning.  But  it  is  important  to 
bear  in  mind  that  a  patient  may  apparently  recover  from  septicfemia 
by  encapsulation  of  the  infectious  matter,  and  yet,  after  the  lapse  of  a 
longer  or  shorter  time,  it  may  again  enter  the  circulation,  being  set 
free,  perhaps,  by  some  slight  trauma  or  by  a  violent  muscular  contrac- 
tion, and  cause  the  death  of  the  patient.  The  experiments  of  Grawitz, 
Behring  and  others  make  it  seem  probable  that  the  powers  of  the  or- 
ganism for  withstanding  septic  intoxication  are  M-eakened  principally 
bj^  the  extensive  disintegration  of  the  red  blood-corpuscles  brought 
about  by  the  toxic  substances. 

Diagnosis  of  Septicaemia. — In  the  diagnosis  of  septicaemia,  the  be- 
haviour of  the  original  wound  or  injury  and  the  inflammatory  mani- 
festations in  it,' the  presence  of  decomposition  of  the  blood,  wound 
secretion,  or  pus,  and  the  presence  of  fever,  and  particularly  the  in- 
creased frequency  of  the  pulse,  are  all  important.  In  those  cases  of 
septicaemia  in  which,  without  noticeable  local  inflammatory  symptoms, 


372  INFLAMMATION   AND   INJURIES. 

there  occurs  within  a  few  hours  of  the  reception  of  tlie  injury  a  severe 
fever,  the  diagnosis  can  usually  be  cleared  up  by  getting  an  exact  his- 
tory of  the  injury.  A  small  and  very  rapid  pulse  is  exceedingly  im- 
portant in  making  the  diagnosis  of  septicaemia.  The  greatest  diagnostic 
difficulties  will  be  met  with  in  those  cases  in  which  no  source  of  infec- 
tion can  be  found,  in  the  so-called  cryptogenic  septicaemia  or  septico- 
pyaemia,  the  origin  of  which  can  only  be  ascertained  during  the  course 
of  the  disease  or  at  the  post-mortem  examination.  Wagner  has  pub- 
lished a  very  instructive  account  of  a  number  of  cases  of  this  kind. 

The  So-called  Surgical  Scarlatina.— In  speaking  of  the  symptomatology  of 
pyaemia  and  septicaemia,  we  mentioned  the  occasioual  occurrence  of  exanthe- 
matous  eruptions  in  the  skin,  particularly  those  which  resemble  the  eruptions 
of  measles  and  scarlet  fever.  Surgical  scarlet  fever,  as  it  is  called,  has  been 
described  by  Thomas,  Riedinger,  and  Hoffa.  It  is  sometimes  a  purely  vaso- 
motor disturbance.  In  addition  to  this  eruption  of  septicsemia,  pvEeniia,  and 
erysipelas,  due  to  vasomotor  disturbance,  there  is  also  a  real  scarlatina 
which  occurs,  particularly  in  children,  after  operations  and  the  reception  of 
wounds.  In  such  cases  the  poison  of  scarlet  fever  passes  directly  from  the 
wound  into  the  general  circulation.  E.  Koch  collected  twenty-six  cases  of 
true  scarlatina  following  operations  and  the  reception  of  wounds  among 
the  patients  of  the  children's  hospital  at  Basel,  and  he  states  that  the  period 
of  incubation  in  this  woimd  scarlet  fever  is  shorter  than  in  the  usual  non- 
surgical form. 

Treatment  of  Septicaemia. — The  treatment  of  septicaemia  consists,  in 
the  first  j^lace,  in  treating  any  injury  which  may  be  present  with  the 
srreatest  sursfical  care.  Every  infectious  wound  disease,  and  conse- 
quently  septicaemia,  can  be  avoided  by  antisepsis  or  asepsis  if  strictly 
carried  out.  If  fever  follows  an  injury  or  an  operation,  the  wound 
should  be  most  carefully  examined,  and  any  retention  of  decompos- 
ing blood,  of  the  wound  secretion,  or  of  pus,  should  be  immediately 
remedied  by  incision  and  drainage,  and  this  sliould  be  followed  by  dis- 
infection with  a  1  to  1,000  solution  of  bichloride  of  mercury  or  a  three- 
to  five-per-cent.  solution  of  carbolic  acid.  The  special  treatment  for 
local  inflammation  aiul  su])puration  is  described  in  §§  67-72.  In  sep- 
ticaemia which  is  the  result  of  a  severe  septic  phlegmon  with  extensive 
gangrene,  it  may  not  infrequently  be  necessary  to  sacrifice  an  entire 
limb,  by  amputation  or  disarticulation,  to  save  the  life  of  the  patient. 
But  it  should  be  borne  in  mind  that  in  an  extensive  septic  cellulitis, 
numerous  free  incisions,  followed  by  thorough  disinfection  of  the  in- 
fective focus  thus  freely  exposed,  may  be  sufficient  to  answer  every 
purpose  ;  though,  on  the  other  hand,  amputation  should  not  be  too  long 
delayed,  as  the  patient  may  even  after  that  die  of  septicaemia.  The 
rest  of  the  treatment  is  wholly  symptomatic ;    there  is  no  effective 


§75.]  PYEMIA.  373 

remedy  for  counteracting  septic  constitutional  infection.  The  treat- 
ment of  the  fever  is  conducted  on  the  rules  laid  down  in  §  02,  If  the 
skin  of  an  infected  patient  is  dry,  ]^>illrotli  i-econnnends  that  the  excre- 
tion of  the  poisonous  substances  be  hastened  by  exciting  pronounced 
diaphoresis,  either  by  placing  the  j)atient  in  a  warm  bath  for  an  hour, 
or  by  wrapping  him  up  warm  in  blankets,  or  by  administering  large 
(pmntities  of  a  hot  drink,  etc.  As  a  matter  of  fact,  we  know  from  the 
experiments  of  Brunnerand  others  that  the  bacteria  are  excreted  in  the 
sweat.  The  septic  diarrhoea  is  combated  with  opium,  tannin,  sub- 
nitrate  of  bismuth,  acetate  of  lead,  enemas  of  starch  paste  containing 
tannin,  opium,  etc.,  but  unfortunately  they  are  nsually  without  much 
effect.  The  diet  of  the  patient  should  be  one  which  is  easily  assimi- 
lated, and  as  nutritious  as  possible.  Alcohol  in  the  form  of  strong 
wines  or  whiskey  should  be  given  freely.  Transfusion,  which  has  been 
used  by  Hueter  in  the  treatment  of  septicaemia,  is  not  to  be  recom- 
mended. 

§  75.  Pyaemia  (Pyohaemia)  or  Pus  Poisoning. — Pyaemia  or  pyohaemia 
(from  TTvov,  pus,  and  al/j.a,  bloodj  was,  until  recently,  understood  to 
mean  an  infection  by  pus,  a  pus  poisoning,  caused  by  the  presence  in 
the  blood  of  the  elements  of  pus.  In  general,  pyiemia  is  characterised 
by  the  development  of  multiple  foci  of  suppuration  (metastases)  in  the 
different  organs,  as  a  result  of  the  wide  distribution  of  the  pysemic  poi- 
son, and'by  an  intermittent  type  of  fever.  It  has  been  stated  before 
(page  363)  that  it  is  often  impossible  to  draw  a  sharp  distinction  be- 
tween pyaemia  and  septicaemia,  and  that  both  of  these  diseases,  clinic- 
ally as  well  as  anatomically,  frequently  occur  together  (septico  pyaemia). 
Consequently  it  is  becoming  more  and  more  a  common  practice  to 
make  no  attempt  at  distinguishing  between  septicaemia  and  pyaemia, 
either  clinically  or  anatomically.  The  same  micro-o.rganisms  are  found 
in  both  affections,  and  it  is  a  secondary  matter  whether  the  infection 
leads  to  suppuration  or  not.  It  would  be  simpler  to  include  both  dis- 
eases under  one  name,  such  as  pyo-septicaemia  or  septico-pyaemia. 

Etiology  of  Pysemia— Micro-organisms.— Koch  has  produced  experimen- 
tally in  rabbits  a  pyaemia  which  is  similar  to  the  pyaemia  occurrino:  in  man. 
He  states  that  this  p\'aemia  of  rabbits  is  excited  by  a  specific  coccus  which 
differs  from  all  other  cocci,  and  in  particular  from  the  coccus  of  the  cheesy 
pus  found  in  rabbits. 

It  used  to  be  believed  that  the  pyaemia  of  man  was  due  to  a  specific  naicro- 
organism,  but  this  theory  has  been  proved  to  be  incorrect;  and,  in  general, 
there  are  found  in  pyaemia  the  same  micro-organisms  as  in  septicaemia  (see 
pages  363-367),  which  is  a  proof  that  the  two  diseases  cannot  be  considered 
etiologically  distinct.  The  common  pus  cocci  are  the  ones  most  constantly 
present  in  pyaemia  (see  pages  321-326).     Any  acute  abscess  may  give  rise  to 


374  INFLAMMATION   AND   INJURIES. 

the  disease.  Under  ordinary  conditions  the  abscess  is  cut  off  by  the  inflam- 
matory infiltration  surrounding  it  from  the  adjoining  healthy  parts,  so  that 
the  cocci  cannot  find  their  way  out  into  the  tissues  and  circulatory  fluids  of 
the  body.  If,  however,  the  system  is  not  protected  in  this  manner,  if  the 
suppurating  area  is  subjected  to  a  certain  amount  of  pressure,  or  if  there  is 
any  considerable  new  addition  of  cocci  to  those  already  present,  a  general 
systemic  poisoning  from  the  cocci,  with  a  constitutional  febrile  disease  and 
the  formation  of  suppurating  foci  in  all  the  different  organs— in  other  words, 
pyaemia— is  easily  produced.  Clinically  there  are  two  main  groups  or  forms 
of  the  pysemic  process.  In  one  there  is  a  large  focus  of  suppuration,  possi- 
bly in  a  joint  or  following  a  compound  fracture,  and  starting  from  this  focus 
there  is  a  continuous  invasion  of  the  whole  body  by  cocci,  accompanied  by  a 
hectic  fever  and  followed  by  death.  In  the  second  group  of  cases  there  is 
no  large  focus  of  suppuration,  but  instead  there  is  only  some  small  injury, 
an  insignificant  cutaneous  abi-asion,  or  a  punctured  wound,  etc  ;  and  follow- 
ing this  single  infection,  there  ensues,  without  any  long-continued  suppura- 
tion at  the  point  of  infection,  a  constitutional  pyagmic  process  and  death, 
though  the  primaiy  injuiy  may  have  cicatrised  a  long  time  previously.  At 
the  post-mortem  examination  there  will  be  found  in  the  internal  organs  the 
characteristic  metastatic  foci  of  suppuration.  Cases  of  this  description  are 
due  to  bacteria  which  start  from  a  single  infection  of  the  wound,  multiply, 
and  are  carried  off  by  the  circulation  and  scattered  throughout  the  body,  and 
wherever  they  lodge  they  give  rise  to  inflammation  and  collections  of  pus. 
In  this  worst  form  of  pytemia  with  metastases  the  ordinary  pus  cocci  are  pres- 
ent. Rosenbach  found  that  the  most  frequent  cause  of  pyaemia  with  meta- 
stases was  the  streptococcus  pyogenes  (see  page  323),  though  typical  exam- 
ples of  pysemia  have  been  known  to  follow  infection  by  other  cocci,  the 
staphylococcus  pyogenes  aureus,  for  instance.  In  addition  to  the  pyaemia 
due  to  cocci  there  is  also  a  pyaemia  due  to  bacilli,  and  essentially  the  same 
micro-organisms  are  present  as  in  septicaemia,  and  hence  the  difficulty  of 
distinguishing  the  two  diseases  etiologically.  The  course  of  pyaemia  in 
man,  as  of  the  other  infectious-wound  diseases,  varies  wnth  the  virulence 
of  the  infecting  micro-organisms,  their  number,  the  su.sceptibility  of  the  in- 
dividual affected,  and  the  anatomical  position  and  peculiarities  of  the  point 
of  infection.  We  know  that  the  virulence  of  the  same  micro-organism  is 
subject  to  variation,  and  that  we  can  artificially  weaken  this  virulence  of 
the  septic  and  pyaemic  micro-organism ;  and  it  has  been  proved,  by  the  ex- 
periments of  Koch,  Gaffky  and  others,  that  we  can  increase  their  virulence 
by  transmitting  the  micro-organisms  in  question  from  one  animal  to  another 
of  the  same  species— for  example,  from  man  to  man. 

It  occasionally  happens  that  the  origin  of  a  py:emia  is  not  clear  during  the 
life  of  the  patient  as  is  true  of  septicaemia,  and  the  disease  is  then  called 
cryptogenic  pyaemia  or  pyoseptica^raia.  In  such  cases  the  focus  of  the  in- 
fection which  gave  rise  to  the  pyaemia  can  usually  be  discovered  at  the  post- 
mortem examination. 

The  Pathological  Changes  Occurring  in  Pyaemia. — The  severe  poison- 
ing of  the  wliole  organism  is  the  predominant  feature  of  septicaemia, 
but  in  pyaemia  the  local  inflammatory  processes  are  characteristic.     In 


§75.] 


PYyEMIA. 


375 


tlie  first  place,  micro-organisms  will  be  found  in  the  vessels,  in  the 
blood,  in  all  the  various  organs,  and  in  the  metastatic  foci  of  suppura- 
tion (Figs.  275,  27G).  In  the  blood  the 
micro-organisms  arc  present  in  the  plasma, 
and  particularly  in  the  white  corpuscles, 
which  in  pyaMuia  as  well  as  in  septicjemia 
are  destroyed  in  relatively  large  numbers. 
The  bacterial  intlammation  of  the  walls  of 
the  veins,  with  the  consequent  formation 
of  thrombi,  which,  under  the  intluence  of 
the  cocci  they  contain,  break  down  and 
suppurate,  is  a  characteristic  feature  of 
pyaemia  (see  §  69,  Phlebitis).  Portions  of 
the  infected  or  su})purating  thrombi  are 
torn  off  and  carried  away  by  the  blood  cur- 
rent and  lodge  here  and  there  as  emboli, 
possibly  in  the  pulmonary  capillaries,  and 
wherever  they  find  lodgement  they  pro- 
duce thrombosis  and  suppuration  (metas- 
tatic abscesses.)  Collections  of  micrococci 
and  metastatic  (embolic)  abscesses  may  thus 
be  found  in  the  muscles  of  the  heart,  the 
endo-  and  pericardium,  in  the  lungs,  pleura, 
brain,  liver,  spleen,  kidneys,  in  the  joints, 
the  marrow  of  the  bones,  the  muscles, 
lymph  glands,  and,  in  short,  in  all  the  dif- 
ferent organs.  Occasionally  a  reddening 
like  erysipelas  makes  its  appearance  in  the 
skin,  but  it  generally  disappears  after  the 
lapse  of  a  few  daj's ;  or  there  may  also  be 
vesicles  or  pustules.  If  the  pyaemia  runs 
a  more  chronic  course,  the  pathological 
changes  are  less  pronounced  ;  the  local  in- 
flammatory processes,  the  metastatic  ab- 
scesses, are  not  so  numerous,  or  they  occur 
in  the  stage  of  convalescence.  The  marked 
emaciation  of  the  patient,  the  fever  caused  by  the  changes  in  the  or- 
gans (see  §  62),  and  the  remnants  of  the  earlier  local  inflammatory  or 
suppurative  processes,  are  characteristic  of  chronic  pyaemia. 

Sometimes,  as  in  septicaemia,  there  occur  cases  of  so-called  crypto- 
genic pyaemia  with  extensive  metastases,  and  it  will  be  impossible  to 
And  the  primary  source  of  infection  either  during  life  or  after  death. 
25 


Fig.  275. — Blood-vessel  in  the  corti- 
cal substance  of  the  kidney, 
taken  from  a  pygemic  rabbit :  a, 
dense  mass  of  micrococci  on  the 
inner  wall,  containing  blood -cor- 
puscles ;  h,  small  tfroups  of  cocci 
between  the  blood  -  corpuscles. 
X  700  (Koch). 


Fig,  276. — Specimen  from  the  liver 
of  a  soldier  who  died  of  pyuemia. 
The  capillaries  between  the  liver 
cells  are  filled  with  masses  of 
micrococci  (Klebs). 


376 


INFLAMMATION   AND    INJURIES. 


Occurrence  of  Pysemia. — Since  the  advent  of  the  antiseptic  period  of 
suretiv.  pvLtmiii  i.as  occurred  much  less  frequently  than  it  used  to. 
Before  the  davs  of  antisepsis  many  hospitals  were  notorious  for  the 
pyaemia  and  infectious-wound  diseases  which  raged  endemically  within 
them,  but  now  in  these  same  hospitals  the  antiseptic  method  of  treat- 
in  »•  wounds  has  caused  the  infectious- wound  diseases  to  disappear  en- 
tirely. The  most  certain  way,  then,  of  preventing  pyaemia  is  to  ob- 
serve the  strictest  antisepsis  and  asepsis. 

Clinical  Course  of  PysBmia, — Ttie  symptoms  of  pymmia  are  character- 
ised bj  the  development  of  collections  of  micrococci  and  multiple 
metastatic  suppurative  processes  starting  in  the  wound  or  source  of  in- 
fection and  involving  all  the  different  organs  of  the  body,  and 'by  an 
intermittent  type  of  fever  with  intercurrent  chills.  According  to  the 
natnre  of  the  wound  the  cases  are  divided  into  two  main  classes.  In 
the  first  group  there  is  somewhere  a  collection  of  pus — for  instance  in 
a  joint — or  it  may  be  connected  with  a  compound  fracture,  and  from 
this  focus  the  whole  body  receives  constant  invasions  by  cocci,  and  at 
the  same  time  there  is  a  remittent  fever  with  intercurrent  chills.  '  In 
the  second  group  of  cases  the  disease  originates  from  the  single  infection 
of  some  small  wound,  and  not  from  a  collection  of  pus  which  has  been 
in  existence  a  long  time.  In  this  second  group  the  micro-organisms 
multiply  in  the  system  and  spread  through  all  parts  of  it,  and  wherever 
thev  find  lodgement  they  excite  inflammation  and  suppuration. 

The  pviemic  fever,  which  has  been  carefully  studied  by  Billroth 
and  Heubner,  does  not,  as  a  rule,  follow  a  regular  course,  but,  in 
the  main,  is  intermittent— that  is,  after  a  marked  elevation  of  tem- 
perature there  is  a  sudden  fall  to  a  normal  or  subnormal  point,  and  the 
temperature  remains  down  for  a  variable  length  of  time  (Fig.  277). 

Pv^emia  is  usually  ushered  in  bja_  rigour,  and  in  its  subsequent 
course  chills  are  of  more  or  less  frequent  occurrence,  the  temperature 
rising  wifh  greater  or  less  rapidity  after  each  chiJl  to  40°  C.  (104°  F.) 
or  higher,  and  jnst  as  rapidly  again  dropping  to  the  normal.  The 
length  of  time  that  each  chill  lasts  varies  very  mnch.  If  the  tempera- 
ture  rises  gradually  there  will  be  no  chills. 

The  intermissions  may  be  repeated  eveij^L  twenty-four  hours_or 
every  other  day,  or  less  frequently.  After  several  days  have  elapsed 
without  any  fever  it  may  be  thought  that  the  pyaemia  has  terminated 
favourably,  when  suddenly  there  will  be  a  fresh  chill  followed  by  high 
fever,  and  then  it  will  be  known  that  the  disease  is  still  active.  This 
peculiarly  irregular  course  of  the  pyaemic  fever  is  due  to  the  fact  that 
from  time  to  time  micrococci  and  the  products  of  their  metaboHsm 
escape  from  some  particular  focus  or  collection  of  them  into  the  gen- 


t;  75.] 


PYAEMIA. 


377 


oral  circulation.     AVlicn  their  inetaljolic  products  have  again  been  ex- 
creted from  the  blood  the  fever  ceases. 

The  condition  of  the  pulse  corresponds  to  the  course  of  the  fever, 
but  KiJnig  is  right  in  stating  that  the  pulse  of  a  pysemic  patient  still 


Puis 

180 
.-_  170 

-  160 
-_  l.>0 

140 

WO 

120 

110 

100 

90 

-  80 
70 

Taye  : 

1 

2 

;? 

4 

h 

6 

7 

8 

9 

10 

11 

f 

a 

/•   tt 

/• 

u 

/' 

a 

f 

a 

/■ 

u 

r 

a 

f 

a 

f 

a 

f 

tt 

f 

a 

_  IX  s 

41,0 

^0,5 

40,0 

30,5 

_39,o 

38,s 

38,0 
37.5 

37,0 

36,5 

» 

/\ 

A 

^ 

/ 

\ 

I.A 

/\ 

l\ 

1 

V 

\ 

'  \ 

1    ' 

{ 

] 

i 

\ 

A 

/ 

\ 

/N 

I 

\ 

^ 

A 

! 

\ 

^. 

A 

\/ 

f 

^ 

\^ 

/\ 

V 

\ 

/ 

v 

V 

V 

V 

\ 

/ 

\ 

V, 

_ 

_ 

\l 

Fig.  277. — Temperature  curve  of  pjiBmia. 

remains  rapid  during  the  time  when  there  is  no  fever,  and  never  en- 
tirely falls  to  the  normal  rate.  The  general  condition  of  the  patient 
varies  with  the  amount  of  the  fever.  The  appetite  is  usually  very 
poor ;  occasionally  there  is  nausea  or  vomiting,  and  in  the  later  stages 
there  is  apt  to  be  a  profuse  diarrhoea.  The  nrine  ordinarily  contains 
albumen  and  casts.  Jaundice  is  common,  and  is  sometimes,  as  in  sep- 
ticaemia, hfematogenous,  in  consequence  of  the  disintegration  of  the 
red  blood-corpuscles ;  and  in  other  cases  it  may  be  caused  by  pyeeniic 
abscesses  of  the  liver  or  by  catarrhal  swelling  of  the  intestinal  mucous 
membrane  in  the  neighbourhood  of  the  ductus  choledochus.  The  other 
symptoms  of  pyemia  are,  in  general,  caused  by  the  metastatic  inflam- 
mations in  the.  internal  organs,  and  vary  greatly  according  to  the  ex- 
tent and  location  of  these  inflammations.  Metastases  in  the  lungs  give 
rise  to  hemoptysis,  to  circumscribed  catarrhal  processes,  to  lobular 
pneumonia,  extensive  pulmonary  abscesses,  and  to  the  different  kinds 
of  pleural  inflammation.  The  metastatic  processes  in  the  abdominal 
organs,  the  liver,  spleen,  and  kidneys,  often  give  rise  to  so  few  symp- 
toms that  they  cannot  be  diagnosticated  during  the  life  of  the  patient. 
Abscesses  occur  with  the  greatest  frequency  in  the  lungs  and  spleen, 
less  often  in  the  liver  and  kidneys.  Metastatic  joint  inflammations  are 
not  uncommon.  A  large  amount  of  albumen  in  the  urine,  with  epithe- 
lium, casts,  and  an  admixture  of  blood,  indicate  an  acute  metastatic  ne- 
phritis. 


378  INFLAMMATION  AND  INJURIES. 

If  metastatic  suppuration  develops  in  the  brain  there  Mill  be  corre- 
sponding symptoms  of  paralysis.  Metastatic  meningitis  will  present  the 
picture  of  diffuse  suppurative  encephalitis. 

The  abscesses  which  may  occur  in  the  superficial  organs,  the  lymph 
glands,  parotid,  joints,  muscles,  and  subcutaneous  cellular  tissue,  etc., 
are  easil}'  recognisable  ;  they  of  teii  cause  no  pain,  and  are  accompanied 
with  little  inflammatory  reaction,  which  is  also  the  case  with  abscesses 
in  the  medulla  of  the  bones.  As  in  septicemia,  there  is,  in  consequence 
of  the  disturbance  of  nutrition  in  the  walls  of  the  vessels,  a  tendency  to 
capillary  haeraorrhages  ;  or,  in  consequence  of  the  suppurative  breaking 
down  of  a  thrombus  and  the  adjoining  wall  of  the  vessel,  which  may 
be  situated  within  a  focus  of  suppuration,  haemorrhages  from  the  lai-ger 
arteries  and  veins  ma}-  take  place,  which  will  endanger  the  life  of  the 
patient.  If  the  pyaemia  starts  from  a  granulating  wound,  it  is  some- 
times noticed  that  the  latter  begins  to  suppurate  less  freely  than  before, 
the  granulations  become  pale  and  flabby,  and  not  infrequently  break 
down  or  undergo  diphtheritic  changes. 

The  duration  of  a  pytemia  is  very  uncertain.  Generally  it  runs  an 
acute  course  (eight  to  ten  to  twelve  days),  often  a  subacute  (three  to 
four  weeks),  less  frequently  a  chronic  course  (two  to  thi-ee  to  five 
months).  As  in  septicaemia,  so  also  in  pyaemia  there  are  cases  which 
apparently  recover  and  then  suddenly,  after  the  lapse  of  months  or  a 
vear  or  more,  there  occurs  a  fresh  acute  general  infection  starting  from 
the  old  encapsulated  pvifmic  focus,  to  which  the  patient  may  succumb. 

Prognosis  of  Pyaemia. — The  prognosis  of  acute  pyiemia  is  almost 
absolutely  bad,  and  yet  there  are  recorded  cases  of  recovery  in  spite  of 
internal  metastases  in  the  lungs,  spleen,  etc.  The  more  frequently  the 
chills  are  repeated,  the  more  rapidly  the  strength  fails,  and  the  earlier 
the  symptoms  occur  pointing  to  internal  metastases,  so  much  the  more 
rapidly  will  the  disease  terminate  in  death.  Chronic  pyaemia  finally 
kills  the  patient  by  exhaustion,  unless  the  focus  of  infection  that  is 
present  is  subjected  to  proper  surgical  treatment. 

Diagnosis. — In  the  diagnosis  of  pyaemia  the  irregular  course  of  the 
fever,  with  intercurrent  chills  and  the  occurrence  of  metastases,  are 
almost  pathognomonic.  Occasionally  pyaemia  is  combined  with  sep- 
ticaemia or  with  erysipelas,  and  then  its  course  is  masked  by  the  other 
infectious-wound  disease. 

Treatment  of  Pyaemia. — Pyaemia  is  treated  in  essentially  the  same 
way  as  septicaemia.  As  in  septicaemia,  the  local  treatment  of  the  source 
of  infection  is  exceedingly  important,  and  should  be  as  energetic  as 
possible — that  is,  every  pyemic  collection  of  pus  should  be  done  away 
with  at  the  earliest  possible  moment.    All  metastatic  abscesses  accessible 


§70.]  INFECTION   BY   CADAVEmr   POISON.  379 

to  surgical  treatment  should  be  o[)euecl  on  antisc])tic  principles  and  dis- 
infected. But  the  treatment  of  fully  developed  pysemia,  as  of  septicae- 
mia, is,  for  the  most  part,  of  no  avail.  It  must,  however,  never  be  for- 
gotten that  we  have  a  certain  means  of  preventing  both  diseases  by 
practising  thorough  antisepsis  in  the  treatment  of  every  wound.  If  the 
patient  is  long  confined  to  bed,  disturbances  of  the  circulation,  as  a 
result  of  cardiac  and  respiratory  weakness,  are  very  apt  to  occur  in  the 
skin,  followed  by  necrosis  of  the  latter — in  other  words,  bedsores  or  de- 
cubitus may  appear,  especially  in  those  regions  where  the  skin  is  closely 
superimposed  upon  the  bones,  as  over  the  sacrum,  the  trochanters,  sca- 
puhe,  and  elbows.  To  avoid  this  complication,  these  areas  of  skin  should 
be  carefully  protected  from  pressure  by  the  use  of  air-  or  water-cushions, 
and  they  should  be  kept  scrupulously  clean  by  washing  them  with  alco- 
hol, etc.  Tlie  treatment  of  bedsores  after  they  have  developed  will  be 
discussed  under  the  sul)ject  of  ulcers  (see  §  93,  Diseases  of  the  Skin),  v 

§  76.  Infection  by  Cadaveric  Poison. — All  individuals  who  have  much 
to  do  with  cadavers  or  dead  animal  matter,  and  so  all  physicians,  anato- 
mists, butchers,  cooks,  etc.,  arc  liable,  on  the  reception  often  of  trifling 
injuries,  to  suffer  from  infectious  inflammations  of  various  sorts,  which 
very  often  lead  to  fatal  general  poisoning.  The  so-called  cadaveric 
poison  is  more  or  less  identical  Avitli  the  poison  of  decomposition.  But 
the  bodies  of  all  animals  which  have  died  from  a  specific  infectious- 
wound  disease,  such  as  erysipelas,  pyaemia,  anthrax,  rabies,  etc.,  still 
harbour  the  specific  bacteria  which  caused  this  infectious  disease,  and 
these  bacteria  remain  capable  of  exciting  the  same  disease  for  the 
first  twenty-four  hours  after  death.  When  decomposition  of  the  dead 
body  sets  in,  the  specific  bacteria  of  pyaemia,  erysipelas,  anthrax,  etc., 
perish,  succumbing  in  the  struggle  for  existence  with  the  bacteria  of 
decomposition.  Consequently  there  may  be  various  poisonous  sub- 
stances in  the  cadaver,  notal)]y  the  excitants  and  products  of  decompo- 
sition, and  also,  in  the  period  immediately  following  death,  the  excitants 
of  specific  diseases.  Therefore  it  can  be  understood  why  the  infections 
of  wounds  from  dead  bodies  have  very  different  clinical  results,  and 
that  septicaemia  and  pyremia,  as  well  as  specific  diseases  like  anthrax 
and  tuberculosis,  are  alike  transmissible  from  cadavers.  Infection  with 
cadaver  poison  usually  takes  place  through  a  small  or  punctured  wound, 
an  abrasion  of  the  skin  from  a  splinter  or  sharp  edge  of  bone,  etc.,  and 
frequently  the  injury  is  so  trifiing  as  not  to  bleed,  and  may  be  entirely 
overlooked.  As  a  general  thing  it  is  better  when  the  wound  bleeds, 
as  then  any  bacteria  which  may  have  lodged  in  it  are  apt  to  be  swept 
out  by  the  flow  of  blood. 

In  the  first  place,  there  are  wound  infections  which  run  a  very  acute 


380  LVFLAMMATIOX   AND   INJURIES. 

course,  particularly  those  in  wliicli  the  infection  is  from  a  septic  cadaver. 
This  may  also  occur  in  surgeons  after  they  liave  operated  upon  a  col- 
lection of  foul  pus  in  a  living  patient.  The  septic-wound  infection 
may,  in  the  worst  cases,  exhibit  the  following  peculiarities :  At  the 
outset  there  is  a  small  injury,  which  generally  causes  only  a  slight 
amount  of  pain,  and  then  very  soon  there  occur  headache,  nausea,  gen- 
eral lassitude,  a  severe  chill,  and  a  rapid  rise  of  temperature.  In  the 
worst  cases,  which  are,  however,  not  common,  death  may  follow  with- 
in two  to  three  days,  preceded  hy  delirium  and  stupor,  and  yet  the  point 
where  infection  took  place  will  not  show  any  noticeable  local  inflam- 
mation. These  are  the  cases  of  acute  septicaemia  which  have  been 
described  in  ji  74.  It  is  still  a  question  whether  these  severe  forms  of 
septicaemia  can  be  caused  by  infection  from  a  non-septic  cadaver — i.  e., 
by  infection  with  the  usual  cadaveric  poison. 

Comparatively  often,  after  infection  from  a  dead  body,  a  circum- 
scribed inflammation  will  begin  in  the  neighbourhood  of  the  wound, 
terminating  in  suppuration,  and  having  a  tendency  to  gangrene,  with 
secondary  lymphangitis,  phlebitis,  and  purulent  lymphadenitis,  for 
example,  in  the  epitrochlear  and  axillary  glands.  Sometimes  the  course 
of  the  disease  is  very  protracted,  and  there  are  cases  which  act  like 
chronic  pyaemia.  These  latter  are  apt  to  occur  after  infection  from  the 
dead  body  of  a  patient  who  has  died  of  pyaemia. 

Cadaver  Tuberculosis  {Verruca  necrogenica). — The  so-called  ana- 
tomical tubercle  is  a  peculiar  chronic  form  of  infection  from  dead 
bodies,  and  is  the  name  given  to  wart-like,  moist,  often  ulcerating 
growths,  which  are  particularly  liable  to  occur  upon  the  backs  of  the 
hands  or  the  knuckles  of  those  who  habitually  handle  cadavers,  such  as 
anatomists,  demonstrators,  etc.  The  anatomical  tubercle  usually  re- 
mains local,  though  there  may  be  attacks  of  acute  lymphangitis  and 
lymphadenitis,  with  possibly  the  formation  of  abscesses.  Baumgarten, 
Riehl  and  others  have  demonstrated  that  the  anatomical  tubercle  is  not 
the  result  exclusively  of  ordinary  cadaver  poisoning,  as  these  investiga- 
tors have  found  tubercle  bacilli  in  the  tubercles.  Consequently  it  is 
an  undoubted  fact  that  some  anatomical  tubercles,  at  least,  are  forms 
of  local  tuberculosis. 

There  occasionally  result  from  cadaver  infection  small  abscesses 
and  pustules  without  any  injury  of  the  skin  having  occurred  ;  under 
these  conditions  the  poisonous  substances  are  lodged  in  the  normal 
cutaneous  pores,  especially  the  sebaceous  glands. 

Zoonotic  Erysipeloid. — In  this  class  of  cases  belongs  the  so-called 
zoonotic  Jlnger-erysipeloid — chronic  erysipelas  or  erythema  migrans — 
which  has  been  described  on  page  351. 


§77.]  SPLENIC   FEVER  OR  ANTHRAX.  381 

Mention  has  been  made  of  tlie  fact  that  very  dangerous,  specific, 
infectious-wound  diseases  can  be  transmitted  to  man  from  the  dead 
bodies  of  human  beings  and  animals,  particularly  within  the  first 
twenty-four  hours  following  death.  This  matter  will  be  discussed 
again  when  we  come  to  the  subjects  of  anthrax,  syphilis,  etc. 

Prophylaxis  and  Treatment  of  Cadaver  Infection. — Yrom  these  facts 
it  follows  that  every  one  having  nmch  to  do  with  dead  human  or 
animal  bodies  should  use  the  greatest  precautions.  To  prevent  cadav- 
eric infection,  one  should  employ  disinfecting  washes  of  absolute  alco- 
hol and  of  one-per-cent.  solutions  of  bichloride  of  mercury  or  three-  to 
five-per-cent.  solutions  of  carbolic  acid.  By  this  means  the  so-called 
anatomical  tubercle  can  be  avoided  with  certainty,  and  after  it  has 
broken  out  it  can  be  caused  to  gradually  disappear  by  the  use  of  bi- 
chloride washes  and  dressings.  If  post-mortem  examinations  have  to 
be  undertaken  upon  bodies  infected  with  pyaemia,  septicaemia,  anthrax, 
etc.,  or  in  case  of  small  scratches  or  wounds  of  the  hands,  it  is  an  excel- 
lent plan  to  cover  the  hands  with  carbolised  vaseline,  rubber  gloves,  etc. 

If  an  injury  is  sustained  during  the  examination  the  blood  should  be 
pressed  out  of  the  wound,  or  the  latter  should  be  sucked  and  then 
thoroughly  disinfected,  no  matter  how  trifling  it  may  be,  with  ab- 
solute alcohol  and  a  one-fif  th-per-cent.  solution  of  bichloride  of  mercury, 
or  a  five-per-cent.  solution  of  carbolic  acid.  These  remedies  are  better 
than  the  application  of  caustic  acids  which  form  an  eschar,  such  as 
nitric  acid,  which  was  at  one  time  very  frequently  used.  After  many 
years  experience  as  an  anatomist,  Lange  advises  that  before  under- 
taking an  autopsy  all  cracks  or  scratches  on  the  hands  should  be 
painted  with  tincture  of  iodine ;  and  he  has  also  found  it  very  success- 
ful to  adopt  the  same  treatment  for  any  wound  received  during  the 
course  of  the  autopsy,  after  it  has  stopped  bleeding.  If  local  inflam- 
mation or  systemic  infection  should  occur,  either  condition  should  be 
treated  upon  the  principles  which  have  been  laid  down  in  a  previous 
chapter.  Long  and  deep  incisions  should  always  be  made  at  an  early 
stage  at  the  point  of  infection,  and  these  should  be  followed  by  the 
continuous  application  of  solutions  of  bichloride  of  mercMry  varying  in 
strength  from  1  to  500  to  1  to  1,000  of  water.  Morphine  should  be 
exhibited  subcutaneously  to  alleviate  pain,  v 

§  77.  Splenic  Fever  or  Anthrax. — Anthrax  is  an  acute  infectious  dis- 
ease caused  by  a  specific  bacillus,  and  is  one  of  the  most  widely  dis- 
tributed and  fatal  of  diseases,  particularly  amongst  cattle,  and  it  is  not 
infrequently  communicated  from  them  to  man.  The  name  splenic 
fever  is  derived  from  the  fact  that  animals  afflicted  with  this  disease 
have  a  very  much  enlarged  spleen. 


J82 


INFLAMMATION   AND   INJURIES. 


Fig.  278. — Blood  from  a  mouse  with  an- 
thrax dried  on  a  cover-crlas.s,  and 
stained  with  methylene  violet.  Ked 
blood-corpuscles  and  anthrax  ba- 
cilli.    X  700  (Koch). 


Etiology  of  Anthrax. — Accurate  knowledge  had  been  obtained  about  the 
origin  of  anthrax  before  anything  was  known  about  the  etiology  of  the  other 
bacterial  infectious  diseases.  In  1849  Pollender  and  Brauell,  working  en- 
tii*ely  independently  of  each  other,  discovered  in  the  blood  of  cattle  dying  of 

anthrax,  fine  rod-shaped  structures,  and 
afterwards  recognised  their  vegetable  na- 
ture. Davaine  was  the  first  to  prove  that 
anthrax  coiild  not  be  excited  in  healthy 
animals  by  inoculating  the  latter  with 
blood  which  contained  no  bacteria,  but  that 
it  could  be  produced  by  inoculations  with 
blood  in  which  the  bacilli  were  present 
(1833).  These  experiments  were  frequently 
repeated,  and  always  with  the  same  results, 
Pasteur,  in  particular,  using  blood  ^vhich 
had  been  freed  from  formed  elements  by 
filtering  it  through  porcelain.  Robert 
Koch  has  furnished  its  with  the  most  im- 
portant facts  concerning  anthrax  and  its 
bacilli,  and  at  present  the  latter  are  the  best 
knowu  of  all  species  of  bacteria. 

Anthrax  Bacillus.— The  anthrax  bacillus 
(bacillus  authracisj  is  a  transparent  rod, 
incapable  of  motion,  possesses  rounded 
ends,  and  is  3  to  10  n  long  and  10  to  1'2  /* 
broad  (Fig.  278).  It  is  found  in  the  blood 
of  animals  suffering  from  anthrax  either 
singlj",  each  bacillus  by  itself,  or  in  fila- 
ments made  up  of  two  to  six  to  ten  little 
rods  connected  together  (Fig.  279).  The 
line  of  separation  between  the  individual  bacilli  is  plainly  distinguishable, 
causing  the  anthrax  filaments  to  assume  a  characteristic  appearance.  The 
bacillus  is  incapable  of  motion  and  is  aerobic— that  is,  it  requires  the  presence 
of  oxygen  to  grow,  the  most  favourable  temperature  being  that  obtained  in  a 
culture  o^en,  and  no  development  takes  place  below  15"  C.  or  above  45^  C. 
The  gelatine  is  rapidly  liquefied.  Gelatine  puncture  cultures  usually  present 
the  appearance  illustrated  in  Fig.  280— that  is,  fine  processes,  thorns,  or 
needles  radiate  from  the  line  in  which  the  puncture  was  made.  On  gela- 
tine plates  colonies  develop  with  a  notched,  uneven  border  or  a  cone-shaped 
coil,  from  which  filamentous  extensions  stretch  out  in  all  directions.  On 
potatoes  the  bacillus  forms  a  dry,  white  layer  (Fig.  281)  ;  on  agar  there 
develops  a  greyish,  slightly  glistening  covering.  In  all  artificial  nutritive 
medi^i  long  filaments  are  formed  made  up  of  many  hundreds,  or  even  thou- 
sands, of  separate  bacilli.  When  the  nutrition  has  become  exhausted  from 
the  ctdture  medium,  provided  oxygen  is  present  and  the  temperature  re- 
mains between  18°  and  40°  C,  the  bacilli  develop  spores,  which  have  the 
shape  of  small  drops  with  a  strongly  refractive  power.  The  best  spores 
form  in  temperatures  between  20°  to  25°  C.  At  the  most  favourable  tempera- 
ture the  spores  are  formed  in  twenty -four  hours;  at  21°  C.  it  takes  seventy  to 


Fig.  279. — Strings  of  anthrax  bacilli, 
from  a  three  hours'  old  culture  of 
the  blood  of  a  sruinea  pig  in  humour 
aqueus.     x  (550  (Koch). 


^77.J 


SPLKXIC    KEVKR    OH    AXTIIKAX. 


383 


1 


^g^ 

^M' 
"^h^ 


seventy-five  hours.  After  the  spores  have  fully  formed  the  bacilhis  breaks 
up,  and  the  spoi-es  are  liberated  and  can  then,  if  they  lodge  upon  a  proi>er 
nutritive  medium,  each  gi*o\v  into  a  bacillus.  The  powei-s 
of  resistiince  possessed  by  anthrax  spores  vary  with  the  par- 
ticular noxious  influence  to  which  they  may  be  subjected,  a 
five-jx^r  cent,  solution  of  carljolic  acid,  for  instance,  killing 
them  in  two  to  thirty  to  fifty  days,  while  steam  at  a  temper- 
atui*e  of  100°  C.  will  destroy  their  vitality  in  three  to  ten  to 
twelve  minutes.  If  bichromate  of  potassium,  in  the  propor- 
tion of  1  to  2,000-5,000,  is  added  to  a  nutritive  medium  con- 
taining anthrax,  such  as  bouillon,  the  bacilli  will  lose  their 
power  of  forming  spores.  The  same  result  can  be  obtained 
by  subjecting  bouillon  cultures  containing  carbolic  acid  (in 
the  proportion  of  8  to  20-10.000)  for  eight  days  to  a  tempei"a- 
ture  ranging  between  30^  and  33"  C  Anthrax  bacilli  thus 
rendered  incapable  of  forming  spores  lose  none  of  their  viru- 
lence when  used  for  inoculating  purposes :  nevertheless,  the 
species  never  regains  its  lost  power  of  developing  spores. 
There  is  some  difference  between  the  shape  and  the  appear- 
ance of  the  cultures  of  the  ordinary  anthi*ax  bacilli  and  those 
rendered  incapable  of  spore  formation.  This  fact  has  pecul- 
iar significance,  showing,  as  it  does,  that  the  bacteria  exhibit 
marked  differences  dei>ending  upon  the  medium  in  which 
they  develop,  and  that  they  cannot  be  distinguished  from 
one  another  without  taking  other  things  into  account  besides 
their  shape  and  the  appearance  of  the  culture.  When  they 
have  exhausted  the  nutritive  principles  from  any  medium  in 
which  they  are  growing  the  bacilli  die  or  take  on  involution 
forms.  The  anthrax  bacilli  develop  no  spores  in  the  living 
animal  body  and  in  the  undecomposed  cadaver,  as  this  pro- 
cess will  only  take  place  when  the  access  of  oxygen  is  unhindered. 

The  best  way  to  study  the  development  of  the  bacilli  under  the  micro- 


FiG.  280.  —  Stab 
culture  of  an- 
thrax in  gela- 
tine. Eight 
il.ivs  old. 


Fig.  281. 


-Pure  culture  of  anthrax  bacilli  upon 

a  boiled  potato. 


0       ^     Oc:^ 


A 


Fig.  282. — Anthrax  spores 
stained  red  with  fuch- 
sin,  some  free,  oth«ra 
shut  up  within  ba- 
cUli  which  hare  been 
staiaed  blue  with  me- 
thylene blue. 


scope  is  to  place  a  drop  of  the  ordinary  culture  bouillon  containing  the  ba- 
cilli in  the  concavity  of  a  slide  which  has  been  hollowed  out  for  the  purpose. 


384  INFLAMMATION   AND   INJURIES. 

Artificial  Attenuation  of  the  Virulence  of  Anthrax  Bacilli.— The  viru- 
lence of  anthrax  bacilli  can  be  weakened  or  attenuated  in  various  ways,  such 
as  subjecting  them  to  a  high  or  low  temperature,  or  making  the  culture  gi'ow 
for  a  long  time— twenty-four  days  or  so — at  a  temperature  of  42^  to  43°  C. 
By  treating  them  in  some  such  manner  it  is  possible  to  render  anthrax  ba- 
cilli entirely  innocuous  (Koch,  Loffler,  etc.).  The  weakened  or  attenuated 
bacillus  forms  metabolic  products  which  differ  from  those  of  virulent  anthrax, 
the  former  producing,  for  example,  acid  in  an  artificial  nutritive  medium,  the 
latter  causing  a  reduction  of  the  nutritive  medium.  Pasteur  tried  to  render 
cattle  and  sheep  unsusceptible  to  anthi'ax  by  inoculating  them  with  bacilli 
which  had  been  attenuated  by  cultivation  at  a  temperature  of  42°  to  43°  C. 
The  principle  is  the  same  as  in  vaccination  with  cow-pox  for  protection  from 
variola;  but  Pasteur's  inoculation  with  attenuated  anthrax  does  not  always 
seem  to  give  immunity  from  infection  occirrring  in  the  ordinary  way  through 
the  intestine.  Haukin.  in  Koch's  institute,  isolated  a  poisonous  albumose 
from  anthrax  cultures  which  produced  in  mice  and  rabbits  immunity  from 
anthrax,  when  exhibited  in  very  small  doses.  The  virulence  of  anthrax 
bacteria  can  be  weakened  by  various  antagonistic  bacteria,  such  as  the  cocci 
of  ery.sipelas,  the  bacillus  pyocyaneus,  Friedlander's  pneumococcus,  the  micro- 
coccus prodigiosus,  the  bacillus  putridus  and  albus,  etc.  Also,  sterilised  cul- 
tures of  these  antagonistic  bacteria  exert,  according  to  Buchner,  a  resti'aint 
upon  the  development  of  antiu'ax  bacilli,  whence  it  follows  that  the  chemical 
substances  derived  from  the  above-mentioned  bacteria,  are  the  active  restrain- 
ing agents.  This  fact  has  been  made  use  of  for  therapeutic  purposes,  and  also 
for  obtaining  immunity  from  anthrax  infection.  Emmerich,  Di  Mattel  and 
Pawlowsky  inoculated  animals  (rabbits)  with  the  erysipelas  coccus,  and  they 
became  afterwards  unsusceptible  to  anthrax.  The  discovery  made  by  Wool- 
dridge  is  exceedingly  interesting.  He  found  that  injections  of  a  solution  of 
fibrinogen  which  had  been  used  for  the  cultivation  of  anthrax  made  ani- 
mals immune  from  this  disease,  and  that  the  same  result  could  also  be  ob- 
tained by  using  fibrinogen  which  had  been  subjected  to  a  slight  chemical 
'  change  without  making  use  of  anthrax  bacilli.  Charrin  and  Bouchard  have 
checked  anthrax  at  its  inception  in  animals  by  inoculating  them  with  the 
bacillus  pyocyaneus,  and  have  cured  the  disease. 

Most  authors  are  of  the  opinion  that  anthrax  bacilli  lose  some  of  their 
virulence  after  having  passed  through  the  body  of  an  animal  which  is  not 
susceptible  to  them.  On  the  other  hand,  Malm  was  able  to  show  that  their 
virulence  is  increased. 

Occurrence  and  Origin  of  Anthrax. — Anthrax  is  widely  distributed  in 
many  countries,  such  as  Russia.  Siberia,  Hungary.  India,  Persia,  and  in  certain 
districts  of  France  and  Germany,  and  yearly  works  destruction  in  herds  of 
cattle,  particularly  during  the  hot  summer  months,  while  in  winter  it  ceases 
its  ravages.  In  England  and  North  America  anthrax  is  not  so  common.  The 
anthrax  bacillus  has  not  yet  been  proved  to  exist  outside  of  the  animal  body. 
In  grazing  animals  (sheep,  cattle,  horses)  the  bacillus  is  most  commonly 
taken  into  the  system  through  the  intestine,  less  often  by  cutaneous  inocula- 
tion. Mice,  guinea-pigs  and  rabbits  are  easily  infected  by  inhaling  the  spores, 
and  are  not  readily  infected  through  the  intestine.  In  man,  anthrax  is  com- 
municated particularly  by  infection  of  small  cutaneous  wounds  (malignant 


SPLENIC   FEVER   OR    ANTHRAX. 


38f 


'?tn 


H^' 


?,' 


Fi().  28.3.— Anthrax  bii- 
cilli  from  a  malignant 
pustule  of  the  skin. 
The  bacilli  are  stained 
with  gentian  violet, 
and  the  tissues  with 
Bismarck-brown.  x 
300. 


-Dogs,  pigs,  and  the 


pustule),  less  often  tlirough  tlie  lungs  uiul  intestine.  The  anthrax  bacilli 
multiply  very  rapidly  in  the  animal  body,  and  are  found  not  only  at  the  point 
of  infection — the  malignant  pustule,  for  example  (Fig. 
283) — but  also  in  the  blood-vessels,  where  they  exist  in  li,"' 
vast  lumibers.  They  are  also  present,  inunediately 
after  the  infection  takes  place,  in  the  lynijjh  and  the 
chyle  when  the  infection  occurs  through  the  intestine. 
In  tiie  malignant  pustule  the  anthrax  bacilli  will  be  fre- 
quently found  enclosed  within  cells,  a  fact  which  can- 
not be  considered  as  supporting  Metschnikoif' s  theory 
of  phagocytosis  (see  pages  272,  273),  as  the  bacilli  were 
probably  dead  before  they  were  taken  up  by  the  cells. 
The  infected  organism  usually  succumbs  very  soon  in 
consequence  of  the  rapid  multiplication  of  the  bacilli  and 
the  poisonous  products  of  their  metabolism.  The  toxic 
products  (albumoses  and  bases)  of  the  anthrax  bacilli 
have  been  studied  by  Hankin,  Lando  Landi,  and  others. 

Natural  Immunity  of  certain  Animals  from  Anthrax. 
majority  of  birds,  are  immune  from  anthrax ;  also  rats,  for  the  most  part,  and 
frogs  under  ordinary  conditions.  But  if  a  frog,  in  whose  lymph  sack  are 
placed  anthrax  spores,  is  put  in 
an  incubation  apparatus,  he  will 
quickly  die  of  anthrax.  Accord- 
ing to  Rohrschneider,  28°  C.  is 
the  lowest  limit  of  temperature  at 
which  anthrax  bacilli  will  devel- 
op within  a  frog's  body.  Accord- 
ing to  Crookshank,  pigs  may  ac- 
quire anthrax.  Ssawtschenko 
stated  that  after  the  spinal  cord  is 
divided  in  doves  they  are  no 
longer  immune  from  anthrax.  In 
general,  the  immunity  which  va- 
rious animals  possess  towards  an- 
thrax does  not  appear  to  be  com- 
plete, as  the  bacilli  can  gradually 
become  accustomed  to  develop  in 
media  which  are  unsuitable  for 
them. 

It  has  been  proved  by  Birch- 
Hirschfleld  and  others  that  an- 
thrax bacilli  can  be  transmitted 
from  the  mother  to  the  foetus  in 
utero.  The  bacilli,  as  it  were, 
grow    into    the    foetal    placenta, 

aided  by  changes  in  the  walls  of  the  vessels,  in  the  tissues  surrounding 
the  vessels,  and  in  the  epithelium  of  the  villi.  The  healthy  placenta 
does  not  normally  permit  the  passage  into  and  through  it  of  micro-or- 
ganisms or  other  formed  elements,  and  the  filter  only  becomes  pervious 


-^^^^^mi 


Fig.  284. — Anthrax  bacilli  in  the  capillaries  of  an 
intestinal  villus  (rabbit),  stained  with  methy- 
lene violet,  and  then  treated  with  potassium 
carbonate,      x  700  (Koch). 


386  INFLAMMATION  AND   INJURIES. 

when  aflFected  by  pathogenic  bacteria  which  bave  gained  access  to  the  pla- 
centa. 

Staining  of  Anthrax  Bacilli.— The  anthrax  baciHus  can  be  rapidly  stained 
by  aqueous  solutions  of  the  aniline  dyes,  and  also  by  Gram's  method.  The 
spores  are  best  stained  at  a  high  temperature  by  means  of  Ehrlich's  aniiine- 
water-fuchsin  solution  or  Ziehl's  solution  containing  carbolic  acid.  Instead 
of  Ehrlich's  fuchsin  solution,  a  correspondingly  made  solution  of  gentian 
violet  can  be  employed  for  staining  the  spores.  After  decolouration  of  the 
substance  of  the  bacilli  the  spores  are  stained  with  Bismarck  brown. 

The  Course  of  Anthrax  in  Animals.— Anthrax  in  domestic  animals  may 
take  one  of  three  courses :  1,  The  apoplectiform  anthrax  (anthrax  acutis- 
simus),  which  lasts  from  a  few  minutes  to  sevei-al  hours  ;  2,  the  acute  an- 
thrax (anthrax  acutus),  lasting  from  a  few  hours  to  several  days  ;  and, 
3,  the  subacute  form  of  anthrax  fanthrax  subacutus),  of  longer  duration. 
There  is  no  period  of  incubation,  or  it  may  occupy  three  to  five  days.  In  the 
more  common  apoplectiform  variety  of  anthrax  (cattle,  sheep)  the  animals 
which  previously  had  apparently  been  in  perfect  health  fall  down  as  though 
struck  with  a  blow,  and  die  often  in  a  few  minutes  with  convulsions,  cyanosis, 
and  dyspnoea.  According  to  Bollinger,  acute  anthrax  in  cattle  and  horses 
begins  with  loss  of  appetite  and  a  chill,  followed  by  a  remittent  or  inter- 
mittent high  fever  (41°  C— 105-8°  F.— and  higher;  ;  there  are  almo.st  always 
spasms,  particularly  clonic  spasms  of  the  extremities.  These  .symptoms  come 
on  in  the  form  of  paroxysms.  The  subacute  form  of  anthrax,  the  anthrax 
carbuncle,  is  characterised  by  carbunculous  and  erysipelatous  swelling  oc- 
curring in  diflFerent  places  in  the  skin,  particularly  in  the  region  of  the  hind 
feet,  while  there  is  only  a  slight  constitutional  disturbance.  The  carbuncle 
begins  to  be  absorbed  frequently  after  the  lapse  of  a  few  days,  and  an  eschar 
and  ulceration  develop  only  exceptionally.  In  about  sixty  to  seventy  per 
cent,  of  the  subacute  cases  fin  cattle  and  horses,  for  example)  death  follows 
with  dyspnoea  and  convulsions. 

Anthrax  in  Man. — Anthrax  occurs  in  man  mainlj  by  transmission 
of  the  anthrax  bacilli  or  their  spores  from  a  diseased  animal,  and  hence 
those  persons  are  particularly  liable  to  the  disease  who  in  their  occu- 
pation come  in  contact  with  infected  animals  or  parts  of  animals.  Such 
persons  are  shepherds,  farmers,  butchers,  veterinary  surgeons,  workers 
in  leather  (furriers,  and  those  who  handle  skins),  and  people  who  are 
employed  in  the  preparation  of  horse-hair,  wool,  and  paper. 

The  so-called  rag-sorters^  disease,  which  runs  a  rapidly  fatal  course, 
presenting  the  appearance  of  pneumonia  with  typhoid  or  septic  symp- 
toms, and  attacks  people  who  sort  and  tear  rags  in  the  manufacture  of 
paper,  is  occasionally  primary  anthrax  of  the  lungs  cau.sed  by  inhaling 
antlirax  spores.  Kraunhals  states  that  the  disea.=;e  is  also  caused  by  the 
bacillus  of  malignant  cedema.  There  are  naturally  various  micro-or- 
ganisms in  rags.  O.  Eoth  describes  three  kinds  of  pathogenic  bacilli : 
Bacillus  I  is  like  the  bacterium  coli,  Bacillus  II  like  the  proteus  homi- 
nis,  and  Bacillus  III  like  Hauser's  proteus  vulgaris  (see  page  366). 


§77.]  SPLENIC  FEVER  OR  ANTHRAX.  387 

Enderlen's  experiments  in  the  Pathological  Institute  at  Munich 
show  that  breathing  in  the  spores  of  anthrax  is  much  more  dangerous 
than  their  ingestion  in  food.  All  "inhalation  animals"  perished  of 
anthrax,  while  of  the  animals  infected  through  food  some  remained 
alive.  Anthrax  is  also  caused  in  man  by  eating  the  tiesh,  milk  or  but- 
ter obtained  from  animals  affected  with  this  disease.  It  may  also  be 
transmitted  by  insects  (Hies)  which  come  in  contact  with  animals  having 
anthrax,  and  the  poison  may  be  communicated  from  man  to  man — for 
example,  at  an  autopsy.  The  disease  starts  either  by  inoculation  of  the 
bacilli  or  of  their  spores  into  the  skin  (it  may  be  a  very  small  interrup- 
tion of  continuity),  or  by  iiihalation  of  the  poison,  or  by  its  introduction 
with  the  food  into  the  alimentary  canal.  The  cases  of  so-called  intes- 
tinal mycosis  recorded  by  E.  Wagner  and  others  are  really  cases  of 
true  anthrax  disease.  In  general  man  is  not  very  disposed  towards  an- 
thrax. Marchand  observed  anthrax  in  a  pregnant  woman  with  fatal 
infection  of  the  child,  Lingard,  experimenting  with  pregnant  rabbits, 
caused  an  infection  of  the  foetus,  and  found  that  in  some  cases  the 
foetus  alone  became  diseased,  in  others  the  mother  also.  Sections 
through  the  placenta  plainly  showed  the  passage  of  the  anthrax  bacilli 
from  the  foetal  to  the  maternal  blood-vessels.  Birch-Hirschfeld's  re- 
cent observations,  which  were  mentioned  before,  are  very  interesting, 
proving,  as  they  do,  the  transmission  of  the  anthrax  bacilli  from  the 
maternal  into  tlie  foetal  circulation.  If  an  abundant  development  of 
anthrax  bacilli  takes  place  in  the  placenta,  the  bacteria  actually  grow 
into  and  through  the  foetal  portion  of  the  placenta  in  a  manner  similar 
to  that  in  which,  after  inhalation  of  anthrax  spores,  the  bacilli  enter 
the  pulmonary  vessels,  as  was  demonstrated  by  Buchner's  experiments. 

The  course  which  anthrax  takes  in  man  varies  according  to  whether 
the  infection  takes  place  externally  or  internally.  When  infection  oc- 
curs through  the  skin  there  is  an  incubation  period  of  three  to  six 
days,  and  then  at  the  point  of  entrance  there  develops  a  biirning  or 
itching  red  nodule  with  a  reddish  or  bluish  bleb,  which  soon  breaks 
and  dries  up,  forming  a  scab.  The  skin  in  the  neighbourhood  of  the 
scab  then  usually  becomes  swjDlleii,  and  sometimes  more  blebs  form. 
The  primary  nodule  at  the  point  of  infection  varies  from  the  size  of  a 
pea  to  that  of  a  nut.  Ordinarily  the  induration  and  a?dematous  swell- 
ing extend  very  rapidly  in  all  directions  from  the  primary  nodule,  and 
the  adjoining  lymphatic  glands  become  enlarged.  After  the  local 
symptoms  have  continued  some  forty-eight  to  sixty  hours  the  constitu- 
tional manifestations  of  the  disease  begin  (high  fever,  great  weakness, 
delirium,  diarrhoea,  severe  vague  pains,  etc.).  If  there  is  a  fatal  termi- 
nation, death  occurs  very  often  with  symptoms  of  collapse,  generally 


388  INFLAMMATION  AND   INJURES. 

after  tlie  disease  lias  lasted  five  to  eiglit  days.  If  there  is  a  favouraLle 
termination  the  scab  is  sometimes  cast  off  by  a  process  of  suppuration. 
In  other  cases  there  is  observed  a  diffuse,  erysipelatous  form  of  car- 
buncle (Yirchovr,  Bollinger) — for  example,  after  infection  by  a  fly-bite, 
and  also  when  the  infection  has  taken  place  internally.  According  to 
E.  Wagner,  the  course  of  anthrax  when  the  infection  has  taken  place 
from  the  intestine  is  characterised  by  the  suddenness  of  the  onset  and 
its  rapid  progress,  with  vomiting,  diarrhcea,  cyanosis,  and  subsequent 
collapse.  When  the  infection  takes  place  through  the  lungs,  as  in  the 
above-mentioned  rag-sorters'  disease,  there  is  observed  a  pneumonia, 
with  typhoid  or  septic  symptoms,  and  for  the  most  part  a  rapidly  fatal 
course.  The  autopsy  in  man  reveals  essentially  the  same  changes  as  in 
animals.  There  are  immense  numbers  of  anthrax  bacilli  in  the  blood- 
vessels, and  particularly  in  the  capillaries  (Fig.  284). 

The  Diagnosis  of  Anthrax,  when  infection  has  occurred  through  the 
skin,  is  made  chiefly  from  the  characteristic  appearance  of  the  malig- 
nant pustule,  and  from  the  patient's  statements  concerning  his  occupa- 
tion, the  origin  of  the  pustule,  etc.  If  necessary,  the  diagnosis  can  be 
cleared  up  by  microscopical  examination  of  the  carbuncle.  For  mak- 
ing the  diagnosis  when  the  infection  takes  place  from  within,  we  must 
refer  the  reader  to  the  text-books  on  internal  medicine. 

Prognosis. — The  prognosis  of  anthrax  in  man,  when  infection  takes 
place  externally,  depends  mainly  upon  whether  energetic  surgical  treat- 
ment is  undertaken  early  enough.  Lengyel  and  Koranyi,  by  adopting 
suitable  local  treatment,  lost  only  thirteen  out  of  one  hundred  and 
forty-two  cases  of  anthrax.  Patients  with  anthrax  resulting  from  in- 
ternal infection  (intestinal,  pulmonary)  very  rarely  recover. 

The  Treatment  of  Anthrax. — In  the  treatment  of  anthrax  in  man 
the  fact  that  the  disease  remains  local  a  longer  time  than  in  animals  is 
of  the  greatest  importance.  If  the  patient  comes  under  observation 
early  enough,  it  is  our  duty  to  destroy  the  point  of  infection  as  rapidly 
and  thoroughly  as  possible — for  instance,  by  extirpation,  by  making 
an  eschar  with  the  Paquelin,  by  cauterisation  with  nitric  acid,  etc. 
According  to  Koch,  bichloride  of  mercury  is  the  most  effective  poison 
for  anthrax  bacilli,  being  capable  of  killing  them  when  used  as  dilute 
as  1  part  to  300,000  of  water.  Consequently  it  is  an  excellent  plan  to 
use  in  and  around  the  point  of  infection  injections  of  one-tenth-per- 
cent.  bichloride,  or  two  to  five  per  cent,  carbolic  acid  (Raimbert  and 
others),  or  dilute  tincture  of  iodine  (one  to  two  of  water,  Davaine).  In 
suitable  cases,  which  come  under  treatment  at  an  early  stage,  with  an- 
thrax infection  located  in  an  extremity,  the  latter  can  be  tied  off  by  an 
elastic  tourniquet  (Nissen).     When  general  infection  has  occurred,  as 


§77.]  SPLENIC  FEVER  OR  ANTHRAX.  389 

shown  by  the  presence  of  bacilli  in  tlie  blood,  little  success  can  be  ex- 
pected from  any  elfective  internal  treatment,  such  as  with  iodine, 
quinine,  carbolic  acid,  etc.,  though  Russian  authors  in  particular  have 
obtained  very  satisfactory  results  by  the  energetic  subcutaneous  and 
internal  administration  of  carbolic  acid  (0'5  gramme  of  carbolic  acid 
internally  and  energetic  injections  into  the  pustule).  The  future  must 
decide  whether  it  is  possible  in  man,  as  in  animals,  to  prevent  anthrax 
or  to  cure  it,  by  the  inoculation  of  other  kinds  of  bacteria  (see  page  384). 

Symptomatic  Anthrax.— Symptomatic  anthrax  (charhon  symptomatique 
of  tlie  French)  is  a  disease  similar  to  anthrax,  atfecting-  cattle,  which  occurs 
endemically  and  mostly  during  the  warm  months  of  the  year  in  many  re- 
gions, notably  the  Bavarian  Alps,  Baden,  Schleswig-Holstein,  etc.,  and  has 
long  been  confused  with  anthrax.     Symptomatic  anthrax  has  not  hitherto 
been  known  to  occur  in  man.     The  disease  has  been  studied  by  Bollinger, 
Kitasato,  and  others.     It  is  character- 
ised by  the  formation  of  irregularly  v        •  *  * 
outlined,   emphysematous,   crackling                ^^^V  ^            *                 *^ 
swellings  of  the  skin  and  muscular           •      I  •*    *1                                 <■ 
tissue,  particularly  on  the  thigh,  and              ^       ^        1  »             ^ 
by  a  peculiar  reddish-black  discolour-     ^             ^        ^  a     ^    ^^^       t 
ation  of  the  diseased  muscles.     In  the       ^                                       • 
bloody  serous  fluid  at  the  focus  of  the          *             ^      |>          i  ^    » 


ation  of  the  diseased  muscles.  In  the 
bloody  serous  fluid  at  the  focus  of  the 
disease  there  is  found  a  chai-acteristic 


disease  there  is  lound  a  criai-acteristic       ^^^  »         t .  " 

bacillus,  which  Kitasato  was  the  first     ^^^  J     '    |        •  ^      ^       •    ^0 

to  obtain  in  pure  cultures  upon  a  solid  ^r  ^,     ^V  ^         ' 


nutritive   medium.      By   inoculating  ^       ^^  '  Q 

animals  with   this  bacillus   Kitasato  ■*  •  *  ^^ 

excited  tjT^ical  symptomatic  anthrax.  ^^^     285.-Bacmi   of    symptomatic    anthrax. 
The  bacillus   of    symptomatic  an-  Spore-beariog  rods  from  a  culture  in  agar. 

,1  ,-rri-_     oo-v    •  4-u        1 Cover -arlass     preparation,    stained     with 

thrax    (Fig.    28a)    is    a    rather  large,  fuchsin.^  x  lOOO  (Frankel  and  Pfeifler). 

slim,  actively  moving  rod  with  plain- 
ly rounded  ends,  generally  occurring  singly,  occasionally  in  pairs,  but  never 
in  long  filaments.  It  is  strictly  anaerobic,  and  when  brought  in  contact 
with  the  oxygen  of  the  air  soon  perishes.  It  grows  at  ordinary  temperatures 
above  18°  C,  but  best  in  the  incubator.  The  spores  form  large,  strongly  re- 
fracting bodies,  rather  long,  and  are  placed  eccentrically  at  the  end  of  the 
rod  (Fig.  28.5).  When  the  spores  become  free  the  rest  of  the  bacillus  speedily 
dies.  The  spores,  which  have  great  powers  of  resistance,  do  not  form  in 
living  animals,  but  do  so  in  dead  bodies  and  in  artificial  cultures.  It  is 
worth  noting  that  the  older  cells,  or  those  which  have  grown  in  media  un- 
suitable for  them,  have  a  tendency  to  develop  involution  forms,  which  some- 
times take  the  shape  of  large,  plump,  spindle-like  segments  enlarged  in  the 
centre,  and  revealing  a  granular  cloudiness  and  an  irregular  contour. 

In  gelatine  to  which  has  been  added  grape  sugar  or  some  other  reducing 
substance  there  develop  within  a  few  days  spherical  masses,  which  rapidly 
liquefy  the  nutritive  medium  (Fig.  286).  In  stab  cultures,  made  in  a  large 
amount  of  gelatine,  a  cloudy,  grey  liquefaction  takes  place  in  the  most  deeply 


390 


INFLAMMATION  AND  INJURIES. 


placed  parts,  with  the  evolution  of  gas  haviug  a  characteristic  acid  odour. 
Agar,  at  the  temperature  of  the  incubator,  becomes  filled  with  bubbles  of  gas 
even  after  the  lapse  of  twenty -four  hours.  In  bouillon,  white  flakes  develop  at 
the  bottom  of  the  vessel,  accompanied  by  the  formation  of  gas.  "When  culti- 
vated at  a  temperature  of  42°  to  43°  C,  the  virulence  of  the  bacilli  is  rapidly 
caused  to  disappear.  The  spores,  particularly  when  subjected  to  high  tempera- 
tures, lose  their  virulence ;  but  if  placed  in  a  twenty-per-cent.  solution  of  lactic 
acid,  and  then  injected  into  susceptible  animals,  they  can  be  made  to  regain 
their  virulence,  and  that,  too,  in  an  increa.sed  amount.  By  inoculating  sus- 
ceptible animals  with  pure  cultures  the  animals  quickly  die  of  symptomatic 
anthrax  with  the  above-described  symptoms.  Under  natural 
conditions,  the  disease  occurs,  in  the  majority  of  cases,  from 
infection  of  small  wounds,  particularly  of  the  extremities, 
less  often  from  infection  through  the  lungs  or  intestine. 
The  poison  is  conveyed  esi>ecially  by  the  spores,  as  the  bacilli 
quickly  perish  when  exposed  to  the  air.  It  is  po.ssible  in  va- 
rious ways  to  obtain  immunity  from  symptomatic  anthrax, 
and  for  this  purpose  "  vaccination  "  with  suitable  "  vaccine  " 
is  very  worthy  of  recommendation. 

The  bacilli  of  symptomatic  anthrax  are  stained  in  the  or- 
dinary way.  The  little  rods,  when  subjected  to  Gram's  meth- 
od, lose  their  stain  again.  The  spores  cannot  be  stained  by 
aqueous  solutions  of  the  aniline  dyes,  but  readily  take  the 
double  stain. 

§  78.  Glanders  or  Farcy  {Malleus). — Glanders  is  an 
infectious  disease  due  to  bacilli,  primarily  occurring,  by 
preference,  in  horses  and  asses,  and  is  transmissible  to 
man  and  all  domestic  animals,  with  the  single  excep- 
tion of  cattle.  The  disease  is  characterised  by  the 
presence  of  peculiar  small  and  large  nqdiiles,  particu- 
larly in  the  mucous  membrane  of  the  respiratory  tract, 
and  in  the  skin,  with  secondary  metastatic  nodules  in 
the  internal  organs  (spleen,  liver,  kidneys,  testicle, 
bones,  etc.). 

Loffler  and  Schiitz  demonsti-ated  four  years  ago  the 


^Mf-Mm 


Fig.  286.— Bacilli 
of  symptomatic 
antnrax.  Pure 
culture         four 


days  old,  after    presence  of  the  characteristic  bacilli  in  the  glanders  nod- 

scattenng  the  ^ 
inoculating  ma- 
terial about 
in  grape-sugar 
gelatine  ;  un- 
stained ;  natu- 
ral size  (Frankel 
and  Pfeiffer). 


ules,  and  made  pure  cultures  of"  the  bacilli  upon  artifi- 
cial nutritive  media,  and  produced  typical  glanders  by 
inoculating  various  animals  with  these  cultures.  Israel, 
Kitt  and  Weichselbaum  have  also  found  the  same  bacilli 
in  glanders,  and  have  successfully  inoculated  other  ani- 
mals with  them,  so  that  there  can  be  no  doubt  that  these  bacilli  are  the 
cause  of  the  disease. 

Glanders  Bacilli.— The  glanders  bacilli  (Fig.  287)  are  slim  rods  similar 
to  tubercle  bacilli,  but  more  regular  as  regards  then*  size,  and  somewhat  broader 


§  78.]  GLANDERS  OR  FARCY.  391 

than  the  latter.  They  possess  no  inherent  power  of  motion.  The  bacilli,  like 
most  of  the  pathogenic  bacteria,  are  facultative  anaerobic,  and  can  be  culti- 
vated in  the  necessary  nutritive  medium  at  temperatures  ranging  between  25° 
and  40°  C,  and  in  the  presence  of  oxygen.  Upon  potatoes  there  form.s,  at  the 
ordinary  incubator  teinperature,  in  the  course  of  about  two  days,  a  yellowish, 
honey-like  layer,  which  afterwards  gradually  becomes  darker,  varying  from 
brownish  to  dark  red.  Upon  agar  the  colonies  form  a  whitish  shining  layer, 
and  npcui  blood  serum,  which  does  not  become  liquefied,  a  clear,  transparent 
covering  in  the  form  of  drops,  which  later  coalesce.  The  formation  of  spores 
by  the  glanders  bacillus  has  not  yet  been  demonstrated,  but  is  considered 
probable  by  Loffler,  Baumgarten  and  Rosenthal.  Prolonged  cultivation 
upon  artificial  nutritive  media  causes  the  glanders  bacillus  soon  to  lose  its 
virulence.  By  inoculation  of  pure  cultures  of  glaaders  bacilli  upon  sus- 
ceptible animals  (horse,  ass,  goat,  cat, 
field  mouse,  house  mouse,  guinea- 
pig),  the  typical  form  of  glanders  is 
produced,  the  glanders  bacilli  being 
mainly  found  in  the  centre  of  the 
specific  glanders  nodules.  Less  sus- 
ceptibility to  glanders  is  evinced  by  ^ 

hogs,  sheep,  rabbits,  and  dogs,  with       /m^:J^  ^'%^  ^^        ii^i^'^'Wi=\ 
the  exception  of  young  dogs,  which        '||^"^  (V  ^0  J^  ,ysf^\^^< 

according  to  Fliigge,  are  very  sus-       J/j^*""^^     ^  ^'^<5^iV''  ^^^'""^ 
ceptible  to  the  disease.     Cattle,  house       '^<j^^'*'v'  '^V     '^^v^'^^S^'^ 

mice,  white  mice  and  rats  are  entire-  %-«-/»         *^    '''*  ,_^   ^•S^'^^ST 

ly  unsusceptible.     Field  mice  die  in  '   '       *"-  •"  'S\>,-         —    ">• 

from  three  to  four  days  after  an  ai-ti-  Fig.  287.— Bacillus  of  glanders.  Pure  cultures 
ficial     subcutaneous     infection    with  UP?°   ,?^>f '°e-agar,     teased     specmen 

.  stained  with  carbolic-fuchsiQ.    x  luu(l'ri.n- 

glanders  ;   guinea-pigs  only  in  the  kel  and  Pfeitferj. 

course  of  several  weeks.     Leo  states 

that  white  mice  lose  their  natural  immunity  and  become  susceptible  to 
glanders  if  tliey  are  made  artificially  diabetic  by  feeding  them  with  phlori- 
zin. The  richer  the  blood  of  a  particular  animal  in  oxygen,  the  less  able  is 
the  glanders  poison  to  develop  (Sanarelli).  By  continuous  transmission  of 
glanders  bacilli  from  one  animal  to  another  it  is  possible  to  cause  a  remark- 
able increa.se  in  their  virulence  (Gamaleia).  Babes  has  obtained  from  glan- 
ders cultures  a  toxalbumen  ("  mallein  "j  which  causes  no  local  disease,  but 
does  cause  symptoms  of  poisoning  (fever,  cramps,  nephritis,  marasmus). 

The  bacilli  exist  in  the  specific  new  tissue  formations  partly  singly  and 
partly  in  irregular  collections  or  bunches  of  several  parallel  rods.  The  glan- 
ders preparations,  or  rather  the  glanders  bacilli,  are  stained  with  concentrated 
alkaline  solutions  of  methyl  blue.  They  are  then  treated  with  greatly  diluted 
acetic  acid,  washed  in  alcohol,  and  embedded  in  oil  of  cedar.  Glanders  bacilli 
cannot  be  stained  by  Gram's  method.  Amongst  the  recent  methods  of  stain- 
ing the  following  are  particularly  good  :  Weigert's  aniline  method,  Unna's 
dry  method,  and  the  method  of  R.  Kiihne  (sections  placed  for  six  to  eight 
hours  in  carbolised  methylene  blue,  then  decolouri-sed  in  acetic  acid,  and 
again  in  distilled  water,  dried  upon  the  slide,  clarified  with  xylol  and  em- 
bedded in  Canada  balsam). 


392  INFLAMMATION  AND  INJURIES. 

Noniewicz  recommends  the  following  combination  of  Loffler's  and  Unna's 
staining  methods  :  1.  Place  the  section  taken  from  alcohol  in  Loffler's  solu- 
tion of  methylene  blue  for  from  two  to  five  minutes.  2.  Wash  in  distilled 
water,  and  stain  for  from  two  to  five  seconds  in  seventy  five  parts  of  one- 
balf-per-cent.  acetic  acid  and  twenty-five  parts  of  one-half-per-cent.  tropaeo- 
lin.  3.  Wash  in  distilled  water.  4.  Dry  upon  the  slide,  apply  a  drop  of 
xylol,  and  examine  in  xylol  and  Canada  balsam. 

According  to  Noniewicz.  glanders  is  caused  partly  by  bacilli  and  partly  by 
a  coccus  form.  The  round  bodies  are  found  particularly  in  subacute  and 
chronic  glanders. 

Glanders  infection,  under  natural  conditions,  generally  occurs  through 
some  small  injury  of  the  skin  or  mucous  membranes,  and  by  inhalation. 
Babes  has  produced  glanders  in  guinea-pigs  by  rubbing  very  virulent  glan- 
ders bacilli  into  the  sound  skin;  whence  it  follows  that  glanders  bacilli  are 
also  able  to  penetrate  into  the  hair  follicles  of  the  uninjured  skin. 

Glanders  in  Animals. — Glanders  occurs  in  horses  and  other  animals  in 
the  form  of  small  or  large  nodules,  or  as  a  diffuse  infiltration.  The  glanders 
nodules  appear  especially  upon  the  mucous  membrane  of  the  respiratory 
tract  and  upon  the  skin.  The  nodules  occurring  in  the  mucovis  membrane 
of  the  respirator}'  tract,  especially  that  of  the  nose,  tlie  lar^Tix,  and  trachea, 
vary  between  the  size  of  a  grain  of  sand  and  a  pea.  At  the  oixtset  they  have  a 
greyish-white  or  greyish-yellow  colour,  and  appear  singly  or  in  groups  and 
are  surrounded  by  a  red  areola.  From  a  suppurative  breaking  down,  often 
within  a  few  days,  there  result  proportionately  large  ulcers,  which  usually 
enlarge  rapidly  by  necrosis  of  the  surrounding  parts,  extending  also  deeply 
into  the  subjacent  tissues.  In  the  lungs  the  glanders  nodules  are  similar  to 
tubercular  nodules,  appearing  partly  as  lobular  foci  of  inflammation  and 
partly  as  interstitial  nodules.  The  pulmonary  glanders  nodules  occur,  ac- 
cording to  Bollinger  and  others,  pai'tly  from  direct  aspiration  of  the  glanders 
poison  and  partly  as  a  result  of  embolism.  In  addition  to  the  circumscribed 
glanders  nodules,  there  ave  also  found  in  the  lungs  diffuse  infiltrations. 

Upon  the  skin  there  occur,  in  the  cutaneous  form  of  glanders,  small 
(miliary)  or  large  nodules,  accompanied  by  a  rapid  suppurative  breaking 
down,  and  the  formation  of  ulcers  which  quickly  extend  and  also  lead  to  in- 
flammation of  the  lymphatic  ves.sels  and  glands.  Cutaneous  glanders  in 
rare  cases  may  also  occur,  by  an  embolic  process,  secondarily  to  primary 
glanders  of  the  respiratory  mucous  membrane.  As  wus  mentioned  before, 
secondary  glanders  may  also  be  found  in  the  spleen  and  liver  and  in  the 
bones,  less  often  in  the  kidneys  and  testes,  as  a  result  of  embolism. 

The  course  of  glandei'S  may  be  acute  or  chronic,  in  the  former  terminat- 
ing in  death  in  six  to  twelve  days  ;  the  latter,  the  more  common  form,  may 
last  for  years. 

Glanders  in  Man. — The  transmission  of  glanders  to  man  does  not 
take  place  very  frequently.  Individuals — sucli  as  butchers,  hostlers, 
cavalry  soldiers,  veterinary  surgeons,  etc. — who  come  in  contact  with 
animals,  especially  horses,  which  have  glanders,  are  particularly  apt  to 
contract  the  disease.  In  man  the  disease  takes  the  form  of  glanders  of 
the  conjunctiva,  less  often  of  the  nasal  mucous  membrane,  and  particu- 


§78.] 


GLANDERS  OR  FARCY. 


393 


Fig.  288. — Acute  glanders  in  man  eight 
days  old.  Well-developed  ulcerations 
of  the  skin  of  the  face  (Birch-Hirscli- 
feld). 


larly  glanders  of  the  slcin,  oriii^inating  in  some  insignificant  injury, es])e- 
cially  about  the  face  and  on  the  hands.  In  man  also,  as  in  animals, 
glanders  may  run  an  acute  or  chronic  course,  and  there  may  develop 
the  above-described  glanders  nodules  and  ulcerations  at  the  point  of 
infection,  and  secondary  nodules  in  the  internal  organs  as  a  result  of 
embolism.  Acute  glanders  runs  a  course  marked  by  severe  typhoid, 
septic  manifestations,  and  sometimes 
it  may  resemble  acute  articular  rheu- 
matism. The  disease  not  infrequent- 
ly begiiis  with  a  general  feeling  of 
malaise,  and  pains  in  all  the  limbs, 
in  the  joints  and  in  the  back.  In 
conjunction  with  a  high  fever  there 
develop  a^the  point  of  infection  typ- 
ical glanders  nodes  which  break  down 
and  ulcerate.  Upon  the  skin  pustular 
eruptions  appear,  which  change  into 
phagedsenic  ulcers  having  a  dirty,  lar- 
daceous  base.  Birch-FIirschfeld  saw 
pemphigus-like  blebs  upon  the  skin 
of  the  nose  and  cheeks,  with  rapid 
destruction  of  the  greater  part  of  the  skin  of  the  face  (Fig.  288).  In 
cutaneous  glanders  there  are  also  not  infrequently  observed  diffuse 
erysipelatous  inflammations,  and  particularly  lymphangitis  and  phleg- 
monous infiltrations  of  the  subcutaneous  cellular  tissue,  terminating  in 
suppuration  or  ulcerative  destructive  processes.  The  secondary  foci  of 
glanders,  particularly  those  in  the  internal  organs,  bear  in  acute  glan- 
ders a  close  resemblance  in  every  respect  to  pya?mic  foci  of  pus,  in 
chronic  glanders  to  cheesy  formations. 

The  above-described  affection  of  the  nose  so  characteristic  of  elan- 
ders  in  the  horse,  is  not  so  frequently  observed  in  man,  and  occasion- 
ally it  first  makes  its  appearance  rather  late  in  the  disease.  Acute 
glanders  is  accompanied  by  high  fever,  and  runs  a  regularly  fatal 
course  within  days  or  weeks,  in  consequence  of  the  increasing  systemic 
infection,  with  the  formation  of  secondary  nodes  or  abscesses  in  the 
internal  organs  as  well  as  in  the  muscles  and  subcutaneous  cellular  tis- 
sue. Chronic  glanders  in  man  has  hitherto  been  less  accurately 
observed.  Kunig  gives  its  average  duration  as  four  months.  It  runs 
a  course  essentially  analogous  to  the  above-described  chronic  glanders 
in  the  horse.  Birch-IIirschfeld  calls  attention  to  the  resemblance  of 
chronic  glanders  to  syphilitic  and  tubercular  disease.  According  to 
Konig,  the  mortality  of  chronic  glanders  is  about  fifty  per  cent. 


394  INFLAMMATION   AND   INJURIES. 

Diagnosis  of  Glanders. — The  diagnosis  of  glanders  in  primary  infec- 
tion of  the  skin  and  nasal  mucous  membrane  is  usually  not  difficult,  in 
consequence  of  the  characteristic  behaviour  of  the  glanders  nodes  tak-en 
in  conjunction  with  the  occupation  of  the  patient.  Internal  glanders 
of  the  tracliea  and  lungs  may  often  be  first  recognised  when  secondary 
affections  of  the  skin  occur,  or  when  the  characteristic  glanders  bacilli 
are  demonstrated  in  the  sputum.  The  demonstration' of  the  bacilli  in 
every  case  is,  of  course,  of  the  greatest  diagnostic  importance.  A  good 
method  for  quickly  diagnosing  glanders  consists  in  mixing  the  suspected 
secretion  with  water,  and  then  injecting  it  intraperitoneally  into  male 
guinea-pigs.  If  it  is  really  glanders,  after  the  lapse  of  two  to  three  days 
there  occurs  a  swelling  of  the  testicles,  which  increases  during  the  next 
few  days.  In  glanders  it  is  of  the  greatest  importance  for  the  patient 
and  his  surroundings  that  the  disease  should  be  recognised  as  early  as 
possiVjle  and  energetically  treated. 

Treatment  of  Glanders. — The  treatment  of  glanders  can  only  be  suc- 
cessful when  the  jioint  of  infection  can  be  destroyed  at  a  very  early  pe- 
riod by  surgical  means — either  by  extirpation,  by  the  Paquelin  or  gal- 
vano-cautery,  or  by  strong  caustics  (nitric  acid,  chloride  of  zinc),  etc. 
The  remainder  of  the  treatment  is  symptomatic,  and  consists  mainly  in 
an  enersretic  local  treatment  of  the  glanders  focus  bv  incision.  Inunctions 
of  mercurial  ointment  (two  to  three  grammes  a  day)  have  been  repeatedly 
used  with  success.  Iodine  and  arsenic  have  been  recommended  internally. 

§  79.  Foot-and-Month  Disease  {AjjhtluT  Eplsooticce). — The  foot-and- 
mouth  disease  is,  according  to  Bollinger,  an  acute  infectious  disease 
which  is  transmitted  exclusively  by  infection  from  one  animal  to  an- 
other. This  disease,  which  is  observed  particularly  in  cattle,  sheep, 
swine,  and  goats,  less  often  in  horses  and  dogs,  is  characterised  by 
moderate  febrile  constitutional  symptoms,  and  by  the  formation  of  blebs 
and  ulcers  upon  the  mucous  membrane  of  the  mouth  (stomatitis  aph- 
thosa),  in  the  clefts  of  the  hoofs,  and  on  the  udder.  The  means  of  in- 
fection— that  is,  the  variety  of  micro-organism — is  not  yet  known. 
Bender  and  Bollinger  found  in  the  ulcers  and  aphthse  micrococci  and 
small  rods.  For  the  poison  to  enter  the  body,  an  injury,  according  to 
Bollinger,  is  not  necessary ;  it  clings  to  the  uninjured  epithelial  layer 
of  the  cavity  of  the  mouth  or  enters  the  system  through  the  lungs,  and 
probably  also  with  the  food.  The  disease  is  very  contagious.  The 
course  of  the  foot-and-mouth  disease  is,  as  a  rule,  favourable,  its  dura- 
tion, according  to  Bollinger,  being  usually  twelve  to  fourteen  days, 
rarely  less.  It  generally  terminates  in  recovery,  and  only  young  and 
cachectic  old  animals  occasionally  succumb  to  the  disease  if  surrounded 
by  unfavourable  conditions. 


§80.]  HYDROPHOBIA.  395 

Occurrence  of  the  Mouth-and-Hoof  Disease  in  Man. — The  transmission 
of  the  disease  to  man  occurs,  according  to  Jiollinger,  most  fre(j[ucntly 
by  drinking  the  uncooked  milk  of  diseased  cows  (Ilertwig,  Jacob),  or 
by  infection  of  a  wound,  particularly  on  the  hands  of  butchers,  or  as  a 
result  of  milking  cows  with  a  vesicular  eruption  on  their  udders,  or  by 
contact  with  the  saliva  of  animals  having  the  disease.  Man  is  oidy 
moderately  susceptible  to  the  poison. 

The  si/»i2>fo//is  of  the  disease  in  man — for  example,  after  infection 
through  milk — consist  in  an  ulcerative  stomatitis,  a  catarrhal  gastro- 
enteritis, accompanied  by  fever,  and  frequently  in  a  vesicular  eruption 
upon  the  hands,  the  face,  and  other  portions  of  the  body.  If  the 
poison  is  transferred  through  a  wound — for  instance,  in  slaughtering 
or  milking  an  infected  animal — the  hand  and  forearm  become  swollen, 
vesicles  form,  and  the  patients  complain  at  the  same  tiine  of  pain  in 
the  moutli  and  dysphagia;  and  later  vesicles  or  pustules  make  their 
appearance  on  other  portions  of  the  skin,  particularly  on  the  face.  The 
disease  lasts  five  to  eight  da)^s ;  and  only  when  the  ulcers  in  the  mouth 
and  on  the  hands  take  on  a  virulent  character  aud  heal  slowly  does  the 
affection  continue  for  two  to  four  weeks.  Secondary  phlegmonous- 
suppurative  inilammations  occasionally  make  their  appearance. 

In  a  great  majority  of  the  cases,  according  to  Bollinger,  the  disease 
terminates  in  recovery,  and  only  rarely,  particularly  in  weak  infants, 
causes  death. 

Treatment. — The  treatment  is  essentially  dietetic.  Care  should  be 
taken  to  use  only  healthy  milk.  If  the  stomatitis  is  intense,  it  is  an 
excellent  plan  to  swab  the  mouth  out  repeatedly  with  a  borax  solution, 
and  to  employ  mild  cauterisation  of  the  erosions  and  ulcers  with  silver 
nitrate  in  the  form  of  a  stick.  The  vesicular  eruptions  on  the  skin 
should  be  treated  with  ungt.  lithargyr.  Hebme,*  vaseline,  boro-glycerine 
ointment,  and  particularly  by  dusting  them  with  bismuth,  iodoform, 
or  oxide  of  zinc  with  starch  (one  to  five  to  ten). 

§  80.  Hydrophobia  {Lyssa^  rahies). — Hydrophobia  is  an  acute  jnfec- 
tipus  disease  which  occurs  chiefly  in  the  dog  and  related  species  of  animals 
— wolf,  fox,  jackal,  hyena.  It  consists  essentially  in  a  disease  of  the 
central  nervous  system,  and  is  characterised  by  a  long  and  extremely 
variable  period  of  incubation. 

Etiology  of  Rabies. — Rallies  originates  in  a  manner  similar  to  syphi- 
lis— that  is,  by  direct  transference  of  the  poison  from  the  bearer  to  the 
receiver.  The  poison  only  takes  root  when  inoculated  into  an  injury 
of  the  skin  or  mucous  membranes. 

*  LTnguentum  diachylon. 
26  -- 


396  INFLAMMATION   AND   INJURIES. 

Rabies  is  almost  always  transmitted  tlirougli  the  bite  of  a  rabid  ani- 
mal, by  whicli  the  poison  is  directly  inoculated  into  the  wound.  The 
experiments  of  Roux  and  Xocard  show  tliat  infection  may  even  re- 
sult from  a  dog  which  at  the  time  when  he  bites  or  licks  an  individ- 
ual is  entirely  healthy,  but  later  becomes  mad.  According  to  ]S^ovi, 
the  poison  of  rabies  may  also  be  transferred  to  animals  by  midges 
and  ilies.  Decomposition  does  not  seem  to  destroy  its  virulence  very 
soon.  In  dead  animals  decomposing  in  the  air,  the  virulence,  accord- 
ing to  Travail  and  Brancaleone,  could  not  be  found  after  twenty-one 
days.  In  buried  animals,  the  nervous  centres  were,  in  some  instances, 
found  virulent  even  after  the  lapse  of  forty-eight  days ;  in  other  cases 
every  trace  of  virulence  had  disappeared  thirty-eight  days  after  burial. 
The  poison  of  rabies  is  destroyed  by  the  digestive  Huids.  Zagari  states 
that  the  virus  of  rabies  loses  its  virulence  very  quickly  when  in  con- 
tact with  oxygen  or  air,  as  it  also  does  in  a  dry  medium  and  when 
the  temperature  is  somewhat  elevated ;  but  in  a  space  devoid  of  air,  in 
carbonic  acid,  in  a  damp  medium,  and  at  low  temperatures,  it  remains 
active  for  a  long  time.  The  poison  of  rabies,  according  to  Pasteur,  is 
always  present  in  the  fresh  saliva,  the  blood,  the  spinal  cord,  and  in 
the  brain,  salivary  and  lachrymal  glands,  the  pancreas,  and  perhaps  the 
mamma  of  animals  affected  with  hydrophobia.  Bombicci  has  also  found 
that  the  suprarenal  capsules  are  always  virulent.  Di  Yestea,  Zagari, 
and  Schaffer  have  shown  that  the  rabies  poison  is  spread  throughout 
the  body  by  the  nerves,  in  addition  to  the  blood  and  lymphatic  vessels, 
and  this  nervous  distribution  of  the  poison  is  the  essential  factor  in  caus- 
ing the  diffuse  myelitis  of  the  central  nervous  system.  The  views  upon 
the  microbe  of  rabies  are  still  divided.  Gibier,  Brigidi  and  Bianchi 
think  that  a  micrococcus  is  the  cause  of  hydrophobia,  whilst  Pasteur 
has  found  a  characteristic  bacillus  whicli  he  attempted  to  breed  in  pure 
cultures,  and  which  for  a  long  time  he  considered  to  be  the  exciting 
cause  of  hydrophobia.  As  yet  the  micro-organism  of  rabies  is  not 
known,  all  attempts  at  artificial  cultivation  having  been  hitherto  unsuc- 
cessful.    The  poison  of  rabies  acts  like  strychnine. 

Transference  Experiments. — Raynaud,  Lannelongue,  Pasteur  and  others 
have  transferred  the  disease  to  rabbits  by  inoculating  them  with  the  saliva 
of  persons  affected  with  rabies.  Pasteur  obtained  from  the  blood  of  these 
rabbits  a  micro-organism  which  he  cultivated  in  veal  broth;  it  was  a  bacillus 
somewhat  contracted  in  the  centre,  and  surrounded  by  a  gelatinous  sub- 
stance. Pastern*  at  first  believed,  as  we  have  said,  that  he  had  found  in  this 
bacillus  the  excitant  of  rabies;  but  he  then  produced  the  same  disease  by  in- 
oculating healthy  human  saliva,  and  he  found  the  same  niicro-organisms  in 
the  inoculated  rabbits.  Vulpian  and  Frankel  obtained  the  same  results  by 
inoculating  rabbits  with  normal  saliva.     Brigfidi  and  Bianchi  found  in  the 


gyo.]  HYDROPHOBIA.  397 

saliva,  and  particularly  in  the  blood  of  threo  individuals  witli  rallies,  before 
and  after  doath,  micrococci  occurring'  sin<i'ly  or  in  pairs  (diplococcij.  Only 
one  of  the  attenii)ts  ;it  inoculation  in  a  ral)bit  was  successful.  Making  use  of 
Pasteur's  method,  ])rain  substance  was  used  for  inoculation  in  this  case.  A 
l)ortion  of  tbe  brain  sub.stance  taken  from  a  child  which  had  just  died  of 
rabies  was  placed  in  a  wound  in  a  rabbit's  brain  which  had  been  expo.sed 
through  a  small  opening  in  the  skull  and  dura.  The  wound  healed  without 
reaction;  the  rabies  began  after  the  la|)se  of  thirty-two  days,  and  in  two  days 
the  animal  was  dead.  The  autopsy  revealed  complete  cicatrisation  at  the 
point  of  operation,  intact  meninges,  intact  brain  and  spinal  cord,  and  no 
suppuration.  In  the  brain,  spinal  cord  and  blood  numerous  micrococci  were 
found.  An  attempt  at  inoculation  with  the  brain  matter  of  this  animal  gave 
no  results. 

Contrary  to  the  views  hitherto  held  upon  the  svibject,  L.  Gibier  has  suc- 
cessfully inoculated  birds  (chickens)  with  hydrophobia,  and  from  these  he 
again  transmitted  the  disease  to  rats  by  inoculation,  which  then  died  with  the 
characteristic  symptoms  of  rabies.  Sometimes  the  inoculated  birds  withstood 
the  disease.  Microscopical  examination  of  the  brain  of  the  diseased  animals 
always  rev^ealed  the  presence  of  the  above-described  micrococcus  of  Gibier. 

Transmission  of  rabies  from  the  maternal  animal  to  the  foetus  in  utero  has 
been  observed  by  Perroncito  and  Carita  in  rabbits  and  guinea-pigs. 

Strengthening  and  Attenuation  of  the  Rabies  Poison  according  to  Pasteur. 
— It  is  well  known  that  Pasteur  has  artificially  strengthened  and  weakened 
the  virulence  of  the  poison  of  hydrophobia.  By  continued  transference  of 
the  poison  in  rabbits  Pasteur  obtained  a  veiy  pure  rabies  poison  which  is 
constant  in  its  effects.  The  fresh  spinal  cord  and  the  medullary  portion  of 
the  brain  of  such  animals  contain  the  strongest  virus.  If  portions  of  the 
spinal  cord  and  brain  are  dnied,  the  virulence  gradually'  diminishes  propor- 
tionately to  the  length  of  time  that  the  drying  is  continued.  Pasteur  has 
been  able,  by  means  of  systematic  inoculations  with  rabies  poison  of  increas- 
ing virulence,  to  make  dogs  immune  from  the  bite  of  mad  dogs  and  from  the 
artificially  transferred  rabies  poison  in  its  most  potent  form.  In  conjunction 
with  these  experiments  on  animals,  Pasteur  undertook,  for  therapeutic  pur- 
poses, protective  inoculation  in  individuals  who  had  been  bitten  by  dogs  pre- 
sumably mad  (see  pages  401-403,  Treatment  of  Rabies).  According  to  Tizzoni 
and  Schwarz,  the  immunising  substance,  as  in  tetanus  and  diphtheria,  is  only 
found  in  the  blood  serum  of  the  inoculated  animals  ;  it  behaves  like  globu- 
line,  and  probably  belongs  to  the  enzymes.  Therefore  they  recommend  that, 
as  in  tetanus  and  diphtheria,  the  blood  serum  of  animals  which  have  been 
rendered  immune  from  rabies  by  inoculation  should  also  be  employed  in  man 
for  prophylactic  and  curative  purposes. 

Action  of  the  Rabies  Poison. — Tlie  action  of  the  still  unknown  rabies 
poison  is  probably  similar  to  that  of  the  tetanus  bacillus.  We  saw  in 
the  chapter  on  tetanus,  which  is  so  closely  related  to  rabies,  that  the 
number  of  the  bacilli  in  the  system  capable  of  demonstration  is  very 
small,  and  that  the  tetanus  bacilli  are  destructive  not  by  their  num- 
bers but  by  the  formation  of  the  poisonous  products  of  their  meta- 


398  INFLAMMATION   AND   INJURIES. 

holism  (toxine).     The  poison  of  rabies  acts,  as  we  have  stated,  similarly 
to  strychiiiue. 

Rabies  in  the  Dog. — The  syinptomatolog>'  of  rabies  in  the  dog  is  briefly  as 
follows:  A  stage  of  incuhmtion  precedes  the  disease,  and  lasts  generally  three 
to  five  weeks,  seldom  less  or  more.  The  longest  duration  of  the  incubation 
stage,  according  to  Bollinger,  is  eight  months.  During  the  incubation  the 
wound  from  the  bite  usually  heals  very  rajjidly,  without  any  particular  in- 
flammatory manifestations.  In  dogs,  two  forms  of  rabies  are  distinguished 
— the  raging  madness,  or  rabies,  and  the  still  rabies.  The  symptoms  of  rabies 
vary  in  other  respects,  according  to  the  race,  sex,  the  state  of  nutrition,  etc., 
of  the  animal.  The  raging  madness  usually  begins  with  a  stage  of  melan- 
cholia, which  is  characterised  by  great  irritability  of  the  animal,  a  pecuHar 
restlessness,  loss  of  appetite,  dysphagia,  and  nausea.  The  dog  shows  a  re- 
markable preference  for  all  sorts  of  indigestible  things,  such  as  hair,  earth, 
straw,  dung,  etc.  The  datiger  for  man  is  the  greatest  during  tliis  stage,  and 
is  so  much  the  more  so  since  the  first  manifestations  are  often  very  insignifi- 
cant. The  initial  stage,  according  to  BolHnger,  lasts  one  half  to  two  to  three 
days  ;  then  follows  the^  stage  of  real  madness — the  irritation  or  maniacal 
stage — lasting  three  to  four  days.  The  characteristic  manifestations  of  this 
stage,  which  only  occur  in  paroxysms,  are  the  change  in  the  disposition,  the 
continued  loss  of  appetite,  a  peculiar  change  in  the  voice,  an  impulse  to  e.scai}e 
and  run  about,  disturbances  of  consciousness,  a  marked  passion  for  biting, 
and  a  rapidly  increasing  emaciation.  A  noticeable  aversion  to  water  is  lack- 
ing, according  to  Bollinger,  and  only  in  exceptional  instances  does  spasm 
occur  in  the  muscles  of  deglutition.  In  the  last  oi^ paralytic  stage  there  is  a 
constantly  increasing  weakness.  The  entire  picture  presented  by  the  bris- 
tling animal  is  frightful  to  look  at.  The  voice  becomes  constantly  hoarser, 
the  dyspnoea  increases,  and  death  generally  occurs  on  the  third,  fifth,  or 
sixth  day,  occasionally  with  partial  or  general  convulsions.  The  termination, 
according  to  Bollinger,  is  always  fatal ;  recovery  has  not  yet  been  observed. 

The  quiet  or  melancholic  form  of  rabies,  which,  according  to  Bollinger, 
makes  up  about  fifteen  to  twenty  per  cent,  of  the  total  number  of  cases 
of  madness,  runs  a  more  rapid  course,  as  thei-e  is  no  maniacal  stage.  In 
the  first  stage  the  manifestations  are  the  same  as  in  the  wild  variety  ;  then 
there  soon^  follows  a  paralysis  of  the  lower  jaw,  the  mouth  remains  wide 
open,  the  voice  becomes  hoarse,  disturbances  of  consciousness?,  raj)id  emacia- 
tion, and'paraiysis  of  the  hind  quarters  follow,  with  death  in  two  to  three 
days. 

The  results  of  the  autopsy  reveal  little  which  is  positive.  The  most  im- 
portant changes,  according  to  Bollinger,  are  a  dark,  tliick  condition  of  the 
blood,  oedema  of  the  brain,  more  or  less  pronounced  catarrhal  changes  in  all 
the  mucous  membranes,  particularly  in  the  respiratory  and  digestive  tracts, 
frequently  combined  with  hypersemia  and  ecchymoses.  hyperaemia  and  cya- 
nosis of  the  parenchyma  of  various  organs,  and  a  high  grade  of  emaciation. 
In  the  stomach  and  intestine  there  are  usually  found,  instead  of  the  normal 
food  stuffs,  indigestible  foreign  bodies  of  various  kinds. 

Hydrophobia  in  Man. — In  man,  rabies  occurs  by  far  the  most  fre- 
quently as  the  result  of  the  bite  of  a  mad  dog  (ninety  per  cent.),  less 


t^HU.J  HYDROPHOBIA.  399 

often  of  cats  (four  per  cent.),  wolves  (four  per  cent.),  and  foxes  (two 
per  cent.),  and  it  always  terminates  fatally,  (.^liildren,  especially,  often 
fall  victims  to  the  disease.  Accordin<r  to  tlie  French  statistics,  one  third 
to  one  fourth  of  all  the  cases  of  the  disease  occur  in  children  under 
tifteen  years  of  age  (Ollivier).  The  question  as  to  how  many  of  those 
who  are  bitten  by  mad  dogs  are  attacked  afterwards  by  the  disease, 
has  received  very  diverse  answers.  JJollinger  is  i-ight  in  maintaining 
that  the  ])ercentage  of  those  attacked  by  the  disease  depends  upon 
whether  one  only  takes  into  account  the  bites  of  really  mad  animals,  or 
also  of  those  M'liich  are  supposed  to  be  mad  ;  and  finally  upon  whether, 
and  when,  energetic  prophylactic  treatment  of  the  wound  made  by  the 
bite  is  adopted.  This  explains  the  discrepancies  in  the  records,  some 
of  wliich  state  that  a  half,  others  a  third,  or  even  not  more  than  five 
per  cent.,  of  those  who  are  bitten  become  affected  with  hydrophobia. 
The  cases  of  death  from  rabies  in  animals  and  in  man  have  diminished 
remarkably  in  states  such  as  Prussia,  where  there  are  stringent  laws 
levied  against  all  dogs  found  running  about  loose,  or  those  thought  to 
have  hydrophobia,  and  where  the  muzzling  of  dogs  is  compulsory ; 
indeed,  in  such  states,  as  Fliigge  has  stated,  rabies  in  man  has  as  good 
as  entirely  disappeared.  As  yet  no  undisputed  case  has  been  observed 
of  the  transmission  of  rabies  from  man  to  man. 

In  niau,  also,  rabies  is  marked  by  a  stage  of  incubation,  generally 
of  eighteen  to  sixty  days,  and  occasionally  of  three  to  six  months.  An 
incubation  of  less  than  fourteen  days  is  rare,  and  only  in  excqjDtional 
instances  are  there  incubations  lasting  from  six  to  twelve  months. 
After  the  termination  of  the  incubation  period,  during  which  the  per- 
son who  has  been  bitten  feels  perfectly  well,  and  the  wound  has  healed, 
usually  with  exceptional  rapidity,  the  rabies  begins  with  psychical 
disturbances  (a  melancholic  frame  of  mind,  excitability,  restlessness, 
loss  of  sleep),  loss  of  appetite,  and  occasionally,  even  at  this  stage,  an 
antipathy  towards  liquids.  The  local  manifestations  at  the  point  of 
the  bite,  which  has  generally  healed,  are  not  constant ;  occasionally 
there  is  observed  an  inflammatory  swelling  of  the  cicatrix,  or  the 
patient  complains  of  pain,  burning  or  itching.  Fever  is  usually  not 
present.  The  prodromal  stage  lasts,  for  the  most  part,  about  twenty- 
four  hours,  rarely  longer.  The'first  symptom  of  true  hydrophobia  in 
man  is  a  spasm  of  the  pharynx  resulting  in  an  inability  to  swallow. 
There  now  occur,  in  the  form  of  paroxysms,  severe  respiratory  and 
pharyngeal  spasms  caused  by  any  kind  of  irritation,  and  especially  by 
the  sight  of  liquids — hence  the  name  ''  hydrophobia."  At  the  same 
time  there  are  observed  reflex  spa,8ms,  for  the  most  part  general  clonic 
spasms,  less  often  tetanic.     There  is  also  a  characteristic  increased  reflex 


400  INFLAMMATION   AND   INJURIES. 

excitability  of  the  nerves  of  special  sense ;  the  patients  suffer  from  a 
perverted  sense  of  smell  ;  they  are  over-sensitive  to  any  noise,  any 
draught  of  air,  etc.  They  are  usually  afflicted  with  a  nameless  dread, 
which  does  not  allow  them  to  get  any  rest;  the  salivary  secretion  is  in- 
creased; the  mind  remains,  in  the  intervals,  for  the  most  part  clear, 
but  from  time  to  time  there  are  maniacal  seizures,  ])ai't]y  as  a  result  of 
the  .terrible  dread  and  the  oppression  in  the  chest  due  to  the  feeling 
of  suffocation,  and  partly  as  a  result  of  the  attempts  of  others  to  re- 
strain them.  The  pulse,  which  is  at  the  outset  full,  gradually  becomes 
weaker  and  more  frequent,  particularly  after  the  paroxysms,  when  it 
reaches  120  to  160  or  more.  The  temjjerature  is  generally  only 
slightly  elevated— 38°  to  38-5°  C.  (100-4°  to  101-3°  F.)— seldom '  reach- 
ing 40°  C.  (104°  F.)  or  more.  After  the  above-described  manifesta- 
tions of  the  second  stage  have  lasted  for  one  to  two  to  three  days,  there 
occurs,  with  an  abatement  of  the  spasms  and  the  difiiculty  in  breathing 
and  swallowing,  a  general  exhaustion  ;  death  then  follows  within  the 
next  few  hours,  with  convulsions,  or  even  perfectly  quietly,  or  less 
often  during  a  recurrence  of  one  of  the  attacks  of  spasm.  The  con- 
sciousness is  usually  unclouded  up  to  the  last. 

The  duration  of  rabies  in  man  is,  in  the  majcjrity  of  cases,  two  to 
four  days,  rarely  more  or  less ;  the  termination,  as  in  animals,  is  regu- 
larly fatal. 

Result  of  Autopsy. — The  results  of  the  autopsy  in  man  are  similar 
to  what  we  have  briefl}'  described  for  rabies  in  animals — that  is,  the 
autopsy  shows  practically  no  characteristic  changes.  Schaffer  called 
attention  to  an  acute  diffuse  myelitis  of  the  central  nervous  system  in 
both  the  grey  and  the  -white  matter,  with  mai'ked  degeneration  of  the 
nerve  fibres  and  ganglia.  Popoff.  often  found  in  the  nerve  fibres. of 
the  central  nervous  system  a  very  high  grade  of  hypertrophy  of  the  axis 
cylinder  and  an  atrophic  condition  of  the  nerve  cells,  with  conspicuous 
pigmentation.  Popoff  saw  these  changes  chiefly  in  the  motor  centres. 
At  all  events,  there  is  a  pronounced  parenchymatous  myelitis,  which 
■^  affects  principally  the  nuclei  of  the  motor  nerves  (Charcot,  Leyden, 
Erb). 

Diagnosis. — In  the  diagnosis  of  rabies  in  man,  the  pharyngeal  and 
respiratory  spasms,  the  increased  reflex  excitability,  and  the  paroxysmal 
nature  of  the  manifestations  of  the  disease  are  characteristic.  Rabies 
can  only  be  confused  with  tetanus  of  the  head,  the  so-called  tetanus 
hydrophohwuH^  which  occurs  in  conjunction  with  wounds  in  the  region 
supplied  by  the  cranial  nerves  (§  73),  as  in  this  also  there  are  pharyn- 
geal spasms.  In  such  cases  the  patient's  statements  may  point  to  the 
correct  diagnosis.     Tetanus,  for  the  most  part,  occurs  between  the  third 


5^80.]  HYDROPHOBIA.  401 

to  the  ciglitli  to  the  tenth  day  after  the  injury,  and  hydrophobia  in  tlie 
fourth  to  the  seventh  week  after  the  reception  of  a  bite  from  a  rabid 
animal. 

Prognosis. — The  prognosis  of  rabies  in  nian  is  regularly  fatal.  No 
certain  cases  of  recovery  from  true  hydropliobia  have  been  observed. 

Treatment  of  Rabies  in  Man. — Prophylaxis  is  of  the  first  impor- 
tance in  the  treatment.  Strictly  enforced  police  laws  against  allowing 
dogs  to  run  about  loose  without  their  masters,  also  a  high  dog-tax,  and 
laws  compelling  the  use  of  muzzles,  are  of  the  greatest  importance  in 
lessening  the  occurrence  and  the  spread  of  hydrophobia.  As  we  men- 
tioned before,  it  has  been  possible  in  this  way  to  very  materially 
diminish  the  frequency  of  the  disease. 

If  a  person  is  bitten  by  a  mad  dog,  or  by  one  supposed  to  be  mad, 
the  poison  at  the  point  of  infection — that  is,  in  the  wound — must  be  de- 
stroyed as  soon  and  as  energetically  as  possible  by  careful  disinfection 
with  a  one-fifth-per-cent.  solution  of  bichloride  of  mercury  or  a  five- 
per-cent.  solution  of  carbolic  acid,  followed  by  energetic  cauterisation 
with  the  red-hot  iron,  the  Paquelin,  or  with  chemical  caustics  (caustic 
potash,  sulphuric  and  nitric  acids).  It  is  also  a  very  good  plan  to  im- 
mediat-ely  suck  out  the  fresh  wound.  Excision  of  the  wound  or  cica- 
trix, with  sul)sequent  cauterisation,  may  be  efficacious,  even  though 
done  several  days  or  weeks  after  the  injury  was  received. 

Pasteur's  Protective  Inoculation. — It  is  well  known  that  Pasteur  has 
undertaken  protective  inoculations  upon  people  who  have  been  bitten 
by  mad  dogs,  after  he  had  made  the  discovery,  as  stated  above,  that 
dogs  become  gradually  unsusceptible  to  hydrophobia  when  inoculated 
with  rabies  poison  the  virulence  of  which  is  gradually  increased.  Bor- 
doni-Ulfreduzzi  has  successfully  practised  Pasteur's  preventive  inocula- 
tion on  dogs  and  on  one  horse.  Tizzoni  and  Schwarz  recommend  the 
use  of  blood  serum  taken  from  animals  (rabbits,  dogs)  rendered  arti- 
ficially immune,  for  prophylactic  and  curative  purposes  in  man,  since 
the  immunising  or  curative  substance  is,  as  in  tetanus,  chiefly  found  in 
the  blood  serum. 

Technique  of  Pasteur's  Protective  Inoculation.— Pasteur's  manner  of  per- 
forming protective  inoculation  is  as  follows  :  A  suitable  amount  of  the  dried 
spinal  cord  of  an  animal  which  has  had  rabies  is  pulverised  with  sterilised 
instruments,  and  to  it  is  added  sterilised  veal  bouillon.  Lymph  is  thus 
obtained  of  varying  virulence,  according  to  the  relative  amounts  of  the  coji- 
stituents  and  the  length  of  time  that  the  cord  has  been  dried.  The  material 
for  inoculation  is  now  injected  with  a  hypodermic  needle  beneatli  the  skin 
of  the  abdomen  a  little  below  the  ribs,  three  fourths  of  a  cubic  centimetre 
being  used  for  full-grown  men  and  a  little  less  for  women,  and  half  a 
cubic  ceulimetre  for  children.     Pasteur  usually  begins  with  a  spinal  cord 


402  INFLAMMATION   AND   INJURIES. 

which  has  been  dried  for  fourteen  days,  then  on  the  following'  day  an  injec- 
tion is  made  of  one  dried  for  thirteen  days,  etc.,  until  for  the  tenth  inocula- 
tion a  spinal  cord  is  employed  which  has  only  been  dried  five  days  ;  the 
patients  are  then  discharged.  Sometimes,  especially  in  bad  cases — for  ex- 
ample, in  Prussians  bitten  by  mad  wolves — according  to  Uffelmann's  reix>rt, 
inoculations  are  made  two  to  tlxree  times  a  day  with  rabies  poison  of  increas- 
ing virulence.  In  this  manner  Pasteur  has  inoculated  a  great  number  of 
people  who  had  presumably  been  bitten  by  mad  dogs  :  of  these  i)eople  some 
died  of  rabies  a  short  time  after  the  treatment,  and  others  later,  and  it  is  not 
impossible  that  death  from  hydrophobia  may  have  occurred  in  some  of  the 
cases  in  consequence  of  the  inoculation.  But  in  a  great  numl>er  of  cases  the 
protective  inoculation  may  have  given  the  wished-for  result.  At  all  events, 
Pasteur's  experiments  are  of  the  greatest  scientific  interest;  but  we  must 
acknowledge,  with  Koch  and  Fliigge,  that  Pasteur's  protective  inoculation  for 
man  has  been  used,  for  practical  purposes,  much  too  soon.  A  more  thorough 
scientific  investigation  of  the  method  should  have  been  made  before  it  was 
put  to  practical  use.  According  to  the  results  hitherto  recorded,  the  success 
of  protective  inoculation  is  uncertain  ;  and,  on  the  other  hand,  there  is  the 
danger  that  people  who  would  otherwise  have  remained  healthy  may,  in 
consequence  of  the  inoculation,  become  infected  with  rabies  and  die. 

Bordoni-Uffreduzzi  has  likewise  employed  Pasteur's  method  of  treatment 
with  the  best  suc^i-ess.  and  in  his  statistics  during  the  years  1886-"88  he  re- 
ports :  Two  hundred  and  forty -one  pei-sons  were  bitten  by  animals  which 
were  experimentally  proved  to  have  rabies  ;  in  the  case  of  two  hundred  and 
forty- five  more,  treated  by  Pasteur's  method,  the  hydrophobia  of  the  animals 
which  bit  them  was  rendered  certain  by  physicians'  certificates  or  by  clinical 
observation  ;  in  forty-five  persons  the  diaguo.sis  of  rabies  was  doubtful. 
Only  six  of  the  fij-st  group  died  ;  of  the  second,  four  :  of  the  third,  none  :  and 
consequently  the  mortality  of  the  whole  list  was  1.88  per  cent. 

When  the  disease  has  once  broken  out,  usually  no  treatment  is  of 
avail.  'SVe  are  then  forced  to  limit  ourselves  to  easing  the  great  suffer- 
ings of  the  patient  by  symptomatic  treatment.  First  of  all,  and  as 
soon  as  possible,  large  doses  of  curare  should  be  injected^  subcutaue- 
ou.sly. 

Pensoldt,  in  one  case  occurring  in  an  eleven-year-old  boy,  employed 
without  success  very  large  doses  of  curare,  injecting  on  an  average  0*01 
to  (r()'2  gramme  every  half  hour,  and  in  the  course  of  one  to  two  and 
a  half  hours  the  full  fatal  amount  of  curare  was  administered.  Curare 
is  very  valuable  in  all  cases  as  a  symptomatic  remedy  for  modifying 
the  pharyngeal  and  respiratory  spasms,  but  it  does  not  possess  an  actual 
curative  effect  upon  the  disease.  Remedies  like  chloral  and  chloroform 
are  indispensable.  For  the  severe  convulsive  and  maniacal  seizures  of 
the  patient  the  continuous  administration  of  chloroform  by  inhalation 
is  probalily  the  best  treatment. 

Recently  various  remedies  have  been  recommended  for  rabies.  For 
example,  Kartschewskji  speaks  well  of  the  internal  use  of  cantharides 


t^81.]  POISONING   BY  INSECTS,  SNAKES,  ETC.  403 

powder  (O'OO  gramme  ^;/'6>  die)  for  a  week,  and  at  tlie  same  time  the 
application  of  emplastrum  cantharidum  to  the  wound  made  by  the 
bite.  According  to  the  experiments  of  De  Bhisi  and  llusso  Travali, 
the  poison  of  rabies  has  Httle  power  of  resistance  against  the  ordinary 
antiseptics  and  caustics,  and  they  recommend  creolin  and  succus  citri. 
The  latter,  as  is  well  known,  has  a  great  reputation  as  a  popular 
remedy. 

§  81.  Poisoning  by  Insects,  Snakes,  Etc. — From  the  bites  of  certain 
insects  and  snakes,  poisoning,  sometimes  mild  and  sometimes  severe, 
may  result,  the  nature  of  which  we  do  not  as  yet  fully  understand. 
Amongst  the  injuries  caused  by  the  stings  of  insects  belong  the  bites  of 
gnats,  fleas,  bugs,  etc.,  after  which,  as  a  result  of  the  introduction  of 
some  irritating  substance,  there  ensue  local  inflammatory  manifesta- 
tions in  the  form  of  redness  and  wheals,  with  itching  and  burning. 
Severer  inflammation  follows  the  wound  inflicted  by  the  sting  which  is 
situated  in  the  posterior  end  of  the  bodies  of  bees  and  wasps.  Their 
sting  involves  a  decided  poisoning  of  the  wound,  which  occasionally 
presents  itself  as  a  very  extensive,  painful  inflammation,  with  redness 
and  swelling,  and  not  rarely  there  may  even  be  alarming  constitutional 
symptoms.  Many  individuals  are  exceedingly  susceptible  to  the  stings 
of  bees  and  wasps.  The  local  inflammatory  manifestations  usually  sub- 
side very  soon.  The  constitutional  symptoms  which  now  and  then 
occur — for  instance,  after  the  direct  injury  of  a  small  cutaneous  vein 
or  a  lymphatic  vessel — consist  sometimes  in  a  peculiar  state  of  collapse  ; 
the  skin  is  cool,  and  covered  with  a  clammy  sweat,  the  pulse  is  small 
and  rapid,  and  occasionally  a  condition  of  coma  is  observed.  These 
threatening  constitutional  symptoms  last  usually  only  a  few  hours,  but 
the  patients  generally  feel  remarkably  feeble  for  several  days.  There 
are  also  many  examples  known  of  men  and  animals  dying  in  a  short 
time  after  being  attacked  by  a  swarm  of  bees  or  wasps.  The  nature  of 
the  wasp  and  bee  poison  is  as  yet  unknown. 

Injuries  from  Tarantulas  and  Scorpions. — I  should  also  mention  in- 
juries produced  by  the  tarantulas  and  scorpions  of  southern  countries, 
with  the  subsequent  extensive  local  inflammations,  which  never  termi- 
nate fatally. 

The  treatment  of  the  above-mentioned  injuries,  particularly  the 
stings  of  bees,  wasps,  tarantulas,  and  scorpions,  is  best  carried  out  with 
ammonia  and  antiphlogistic  remedies.  As  Billroth  says,  bee-tenders 
employ  scorpion  oil  as  a  kind  of  antidote  for  bee  stings — that  is,  olive 
oil  in  which  some  scorpions  have  been  kept. 

Injuries  from  Venomous  Snakes. — The  injuries  due  to  poisonous 
snakes  are  relatively  rare  in  our  zones  as  compared  with  the  tropics. 


404  INFLAMMATION   AND   INJURIES. 

The  nature  of  the  snake  poison  is  as  yet  unknown  to  us ;  it  is  probably 
a  poisonous  alkaloid  which  is  contained  in  the  secretion  of  the  poison 
glands.  In  Europe  there  are  ordinarily  found  only  three  kinds  of 
poisonous  snakes — the  vipera  berus,  the  vipera  redii,  and  the  vipera 
aspis.  These  poisonous  snakes  have  two  hook-shaped  poison  teeth,  in 
which  the  excretory  ducts  of  small  glands  empty..  At  the  time  of  the 
bite  the  glands  empty  their  poisonous  juices  into  the  wound.  By 
drying  the  secretion  from  the  poison  glands  of  forty  asps,  Karlinski 
obtained  fifteen  grammes  of  a  white  amorphous  mass,  easily  soluble 
in  water  and  alcohol,  a  twenty-per-cent.  aqueous  solution  of  which  cor- 
responded in  its  action  to  the  fresh  poison  coming  from  the  poison 
glands  of  the  adder.  The  bites  of  the  above-mentioned  poisonous 
snakes  are  in  general  not  very  dangerous ;  according  to  Billroth,  about 
two  die  out  of  a  total  of  sixty  bitten. 

The  iiianifestat'ions  after  the  bite  of  these  poisonous  snakes  consist 
in  a  very  painful  local  inflammation,  in  coagulation  of  the  blood  in  the 
parts  immediately  adjoining  the  wound,  in  thrombosis  of  the  blood- 
vessels, not  infrequently  in  gangrene,  vomiting,  high  fever,  a  feeling 
of  anxiety,  cramps,  great  weakness,  etc.  The  affected  portion  of  the 
body  is  subsequently  often  remarkably  devoid  of  sensation.  Occasion- 
ally death  occurs  in  a  relatively  short  time,  preceded  by  an  increasing 
state  of  collapse.  If  a  person  bitten  by  a  viper  redii  survives  the  first 
two  days,  the  prognosis  is  in  general  favourable. 

The  best  treatment  for  these  snake-bites  is  to  immediately  suck  the 
wound — a  procedure  entirely  freelrom  danger — then  to  wash  out  the 
wound  with  bichloride  of  mercury,  carbolic  acid,  absolute  alcohol,  etc., 
and,  when  possible,  to  cauterise  the  wound  with  some  energetic  liquid 
caustic  or  with  the  hot  iron.  To  prevent  the  rapid  absorption  of  the 
poison,  it  is  a  very  good  plan  to  employ  the  popular  remedy  of  tying 
off  the  injured  portion  of  the  body — an  extremity,  for  instance — as 
soon  as  possible,  close  above  the  bite.  Energetic  antiphlogistic  meas- 
ures are  adopted  for  the  local  inflammation.  Finally,  the  internal  and 
subcutaneous  administration  of  liquor  ammonii  fortior  has  been  recom- 
mended, a  hypodermic  syringe  full  (one  part  liq.  ammon.  fort,  with 
one  to  two  to  three  parts  water)  being  used  as  a  subcutaneous  injec- 
tion;  internally  ten  to  twelve  drops  of  the  same  mixture  should  be 
given  many  times  each  day.  Karlinski  praises  the  injection  of  one 
per  cent,  chromic  acid  and  of  chlorine  water  (Lenz)  into  the  wound 
made  by  the  bite  and  the  surrounding  parts.  Large  doses  of  alcohol 
(whiskey)  and  energetic  active  motion  of  the  muscles  are  in  great  re- 
pute amongst  the  laity. 

The  most  dangerous  poisonous  serpents  are  the  American  rattle- 


§83.]  THE  POISONING   OF   WOUNDS   BY   INDIAN   ARROW  POISON.    405 

snakes  and  the  eubra  species  of  Asia  and  Africa.  After  injuries  in- 
flicted by  the  bite  of  these  snakes  there  ensue  extremely  severe  local 
inflammations  which  terminate  in  gangrene.  The  constitutional  mani- 
festations are  like  those  in  hydrocyanic-acid  poisoning,  consisting  in  a 
feeling  of  dread,  oppression  of  the  chest,  cyanosis,  delirium,  convul- 
sions, and  stupor.  Death  follows,  occasionally  in  a  few  hours,  with 
symptoms  of  collapse  ;  in  fact,  death  not  infrequently  occurs  before  any 
local  symptoms  make  their  appearance.  It  is  of  practical  importance 
to  note  that  the  poison  may  even  have  a  fatal  effect  when  in  a  dried 
condition  or  in  an  alcoholic  preparation.  According  to  Cohnheim, 
death  from  a  poisonons  snake-bite  is  in  all  probability  caused  essen- 
tially by  the  disintegration  of  the  red  blood-corpuscles. 

The  treatment  is  in  general  like  that  for  the  bite  of  a  vipera  berns. 
Richards  and  De  Lacerda,  basing  their  opinion  upon  experiments  with 
the  poison  of  the  cobra,  recommend  the  subcutaneous  injection  of  a 
five-per-cent.  aqueous  solution  of  permanganate  of  potassium  (eight 
to  twelve  grammes  of  the  solution).  Immediately  after  the  reception 
of  the  bite  a  ligature  should  be  placed  on  the  proximal  side  of  the 
wound,  the  ligature  not  being  removed  until  several  minutes  after 
making  the  injection.  In  one  case  potassium  permanganate  was  in- 
jected with  success  twenty-five  minutes  after  the  reception  of  the  bite. 
The  length  of  time  within  which  a  subcutaneous  injection  of  potas- 
sium permanganate  is  attended  with  success  becomes  proportionately 
prolonged  when  a  ligature  is  applied  above  the  poisoned  wound.  If 
the  poison  has  already  caused  constitutional  symptoms,  Richards's  ob- 
servations show  that  the  injection  of  permanganate  of  potassium  has 
no  effect. 

§  82.  The  Poisoning  of  Wounds  by  Indian  Arrow  Poison. — This  is 
perhaps  the  best  place  briefly  to  consider  the  wound  infections  pro- 
duced, for  instance,  by  the  poisoned  points  of  arrows  used  by  the  Indians. 
According  to.W,  T.  Parker,  the  arrow-points  of  the  American  Indians 
are  poisoned  with  a  devilish  cunning,  and  the  process  is  frequently  kept 
secret.  Vegetable  poisons,  especially  curare  or  urari,  or  decomposing 
putrid  substances  (decomposing  meat  and  blood,  for  instance,  of  dead 
enemies,  decomposing  liver,  etc.),  or  snake  poisons,  made,  for  ex- 
ample, from  the  crushed  heads  of  serpents,  are  employed.  There  is 
also  a  partiality  for  using  the  liver  of  an  ox,  which  is  pierced  with 
arrows  and  allowed  to  decompose  in  the  sun ;  crushed  ants  are  also 
added  to  the  mixture.  The  symptoms  of  poisoning  differ  according  to 
whether  a  vegetable  poison  like  curare,  or  putrid  substances,  or  animal 
poisons  like  those  of  snakes,  or  mixed  poisons  are  employed.  The 
action  of  curare,  the  real  arrow  poison  of  the  Indians,  is,  as  is  well 


406  INFLAMMATION   AND   INJURIES. 

known,  to  paralyse  voluntary  muscles,  except  those  of  the  heart  and 
respiration.  The  cardiac  and  respiratory  activity  only  succumb  after 
poisoning  with  very  large  doses  of  curare.  The  American  Indians  still 
commonly  use  the  arrow,  in  addition  to  firearms,  for  war  and  the  chase. 
The  point  of  the  war  arrow,  according  to  AV.  T.  Parker,  is  short  and 
broad,  and  so  formed  as  to  enter  easily  between  the  ribs  of  a  man. 
The  hunting  arrow  is  the  weapon  to  be  most  feared.  The  Indians 
can  shoot  this  about  one  hundred  metres,  and  with  as  great  accuracy 
as  the  best  modern  revolver.  The  arrow  penetrates  the  tissues  with 
great  force,  and  can  perforate  the  stoutest  bones.  Gutters  are  made 
in  the  shaft  to  permit  the  blood  to  escape  from  the  wound.  The  point 
of  the  arrow  is  fastened  to  the  shaft  in  such  a  manner  that  when  it 
becomes  wet,  and  consequently  when  it  is  in  a  wound,  or  when  at- 
tempts are  made  at  extraction,  it  easily  becomes  loosened  and  remains 
in  the  wound.  The  arrow-points  are  made  of  iron,  pebbles,  bones, 
glass,  wood,  etc.  Tlie  Indians  are  greatly  skilled  in  removing  the 
points  of  arrows  from  wounds  in  which  they  have  stuck.  A  counter 
opening  is  often  made  through  which,  after  cutting  off  the  shaft,  the 
arrow-point  is  withdrawn. 

Appendix. 

Chronic  mycoses :  Tuberculosis  (scrofula),  syphilis,  leprosy,  actinomycosis. 

§  83.  Tuberculosis. — Of  the  chronic  infectious  diseases  of  bacterial 
origin  which  are  of  importance  for  the  surgeon,  tuberculosis  is  very 
prominent.  By  tuberculosis  (from  tuberculiim,  a_npdule)  we  under- 
stand an  infectious  disease  due  to  a  rod-shaped  micro-organism,  the 
bacillus  tuberculosus  (Koch),  and  characterised  anatomically  by  the 
formation  of  nodules,  the  so-called  tubercles.  On  the  24th  of  March, 
1882,  Eobert  Koch  announced  to  the  Physiological  Society  at  Berlin 
that  he  had  found  the  cause  of  tuberculosis,  and  that  the  disease  was 
alone  produced  by  a  single  specific  bacillus  which  he  had  made  grow  in 
pure  cultures.  The  sensation  created  by  Koch's  discovery  was  exceed- 
ingly great,  and  his  classical  experiments  in  tuberculosis  will  always 
excite  the  profoundest  admiration. 

"We  shall  here  discuss  mainly  surgical  ttiberculosis — that  is,  the 
tuberculosis  coming  within  the  jurisdiction  of  surgical  therapy,  and  so 
particularly  the  very  common  tuberculosis  of  the  skin,  mucous  mem- 
branes, lymphatic  glands,  sheaths  of  tendons,  bones  and  joi^nts,  etc.  In 
whatever  part  of  the  body  the  tubercle  baciUi  develop  and  multiply, 
they  always  give  rise  to  tlie  formation  of  characteristic  tubercles — that 
is,  to  cellular  nodules  devoid  of  vessels,  which,  after  the  lapse  of  a  defi- 


§83.] 


TUBERCULOSIS. 


407 


^  *  «  •  «;  s  ,, ., 


v.T 


nite  length  of  time  and  in  a  certain  stage  in  tlieir  development,  die, 
usually  by  a  ])rocess  of  cheesy  degeneration. 

Origin  and  Structure  of  the  Tubercles. — These  tubercles  (Fig.  289) 
originate,  according  to  the  very  careful  investigations  of  Baumgarten, 
Cornil,  and  others,  in  the  following  manner :  In  consequence  of  the 
growth  of  the  bacilli  in  any  particular  tissue,  there  occurs,  in  the  first 
place,  a  proliferation  of  the  fixed  tissue  cells,  which  begins  with  the 
process  of  caryomitosis  and  leads  to  the  formation  of  protoplasmic, 
epithelial-like  or  epithelioid  cells.  The  tubercles  are  consequently  at 
first  made  up  essentially  of  groups  of  epithelioid  cells  which  lie  within 
the  connective-tissue  stroma  of  the  original  tissue,  which  has  been 
partly  absorbed  and  partly  pushed  aside — the  so-called  retkiulum  of 
the  tubercle.  Some  epithelioid  cells  have  one  nucleus,  others  two, 
while   still    others   are  polynu-  r 

clear — so-called  giant  cells — in 
which  there  are  often  found  a 
very  great  number  of  large  oval 
nuclei.  The  giant  cells  proba- 
bly originate  not  by  the  fusion 
of  several  epithelioid  cells  but 
by  the  proliferation  of  the  nu- 
clei of  a  single  cell.  In  spite 
of  the  vigorous  growth  of  the 
fixed-tissue  cells  (connective-tis- 
sue cells  ;  cells  of  the  walls  of 
the  vessels,  epithelium)  no  new 
formation  of  capillaries  takes 
place  within  the  nodules.  After 
the  proliferation  of  the  original 
tissue  cells  there  occur,  sooner 
or  later,  inflammatory  changes 
in  the  vessels  of  the  diseased  region  which  lead  to  an  emigration  of  the 
colourless  blood-corpuscles,  first  in  the  perii^hery  and  then  later  in  the 
centre  of  the  nodules.  The  nodules,  which  are  at  the  outset  made  up 
of  large  cells,  thus  come  to  be  made  up  more  and  more  of  small  round 
cells.  If  the  emigration  of  leucocytes  occurs  at  a  very  early  stage  and 
masks  the  growth  of  the  fixed  cells,  it  is  possible  for  the  nodules  to  ap- 
pear to  be  made  up  of  small  cells  from  the  very  beginning.  "When  the 
grey  transparent  nodules,  which  are  about  the  size  of  millet  seeds,  have 
reached  the  stage  of  the  small-celled  tubercles  they  are  no  longer  capa- 
ble of  further  development,  and  there  now  occurs  a  retrograde  meta- 
morphosis, the  cells  perishing  by  fatty  or  '^'cheesy  degeneration  or  by 


Fig.  289. — Tuberculosis  of  lymph  glands  :  T.  tu- 
bercle with  giant  cells  in  the  centre,  and  large 
celled  tissue  between  the  separate  tubercles ; 
V.  2\  cheesy  tubercle ;  Z,  tissue  of  the  lymph- 
gland,  stained  with  haiiiatoxyln.     x  200. 


408  INFLAMMATION   AND  INJURIES. 

coagulation  necrosis,  and  forming  homogeneous  masses.  Frequently 
the  tubercular  foci  become  permeated  with  lime  salts,  and  finally  form 
mortar-Hke  concretions.  The  typical  death  of  the  tubercle  is  by  casea- 
tion or  cheesy  degeneration  (Fig.  289,  v.  T.).  The  cause  of  these  tu- 
bercles—  that  is,  the  cause  of  tuberculosis  — is  the  above-mentioned 
rod-shaped  bacillus  discovered  by  H.  Koch  (bacillus  tuberculosus,  Fig. 
224:,  page  258). 

Tubercle  Bacilli. — The  characteristic  bacilli  present  iii_tlie  nodules 
are  found  either'  in  the  interior  of  the  cells — for  instance,  within  the 
giant  cells  (Fig.  290)— or^'between  the  cells ;  also  in  the  blood  of  those 

suffering  from  general  tu- 
berculosis, in  the  sputum  of 
those  with  tuberculosis  of 
the  respiratory  tract,  in  the 
urine  in  genito-urinary  tu- 
berculosis, in  pus,  etc.  To 
Koch  alone  is  due  the  great 
credit  of  having  proved,  by 
inoculations  with  pure  cul- 
tures of  his  bacillus,  that  the 
bacilli  present  in  tuberculo- 
sis are  the  sole  cause  of  the 
disease. 

Fig.  290. — Giant  cell  with  tubercle  bacilli.  _,       ,  -.r     ■,  ,     m   ■,        i-n 

X  700  (Koch).  Robert  Koch  s  Tubercle  Ba- 

cilli.— The  tubercle  bacilli  are 
fine,  generally  slightly  curved  rods  from  1'6  to  3'5  ^i  in  length,  incapable  of 
spontaneous  movement.  They  usually  occur  singly,  rarely  in  pairs,  and 
sometimes  filaments  are  seen  made  up  of  five  to  six  segments.  Whether  or 
not  the  bacilli  form  spores  has  not  hitherto  been  determined.  When  the  ba- 
cilli are  stained  there  are  occasionally  seen  bright  vacuoles  having  a  regular 
arrangement,  which  are  suggestive  of  spores.  The  bacilli  are  extremely  re- 
sistant, probably  as  a  result  of  their  very  firm  membrane  or  envelope  ;  hence 
they  do  not  lose  their  virulence,  though  dried  for  a  month,  or  subjected  to 
high  temperatures  nearly  reaching  the  boiling-point,  or  when  subjected  to 
decomposition  or  the  acid  gastric  juice. 

The  cultivation  of  the  facultative  anaerobic,  strictly  parasitic  bacteria  o\xt- 
side  of  the  animal  body  is  accompanied  with  difficulties.  They  thrive  best  of 
all  upon  the  hardened  blood  serum  of  sheep,  cattle,  and  calves  in  the  incuba- 
tion apparatus,  at  a  temperature  of  37°  to  38°  C.  (98 '6°  to  100 '4°  F. ).  A  tubercle 
containing  bacilli  or  some  similar  substance  taken  from  a  slightly  caseous 
lymph  gland  can  be  used  for  the  seed.  Below  89°  C.  and  above  43°  C.  tu- 
bercle bacilli  cease  to  grow.  At  an  incubator  temperature  of  37°  to  38°  C,  if 
the  cxdture  is  very  carefully  protected  from  impurities  and  from  becoming 
mixed  with  othe^  bacteria,  there  develop  upon  the  blood  serum  characteristic 


§83.]  TUBERCULOSIS.  409 

greyish-wliito,  small  dry  scales  or  crunil)s,  vvliich  become  visible  through  the 
microscope  within  five  to  six  clays,  but  to  the  naked  eye  only  after  the  lapse 
of  ten  to  fifteen  days.     From  the  end  of  the  thix'd  week  on,  the  appearance  is 
very  characteristic.     In  a  test  tube  the  tubercle  bacilli 
thrive  exceedingly  well  upon  meat-peptone  agar  to  which 
has  been  added  three  to  live  per  cent,  of  glycerine  (No-     (  :'^ 

card,  Roux).  This  glycerine  agar  is  at  pi-eseiit  almost  '- 
exclusively  used  for  making  pure  cultures,  and  is  displac- 
ing more  and  more  the  blood  serum  which  is  so  difficult  • 
to  sterilise.  When  tubercle  bacilli  are  inoculated  with 
the  platinum  wire  upon  glycerine  agar,  the  first  colonies 
will  be  observed  along  the  line  where  the  wire  was  drawn.  . 
about  foui'teen  days  subsequently.  If  the  culture  is  al- 
lowed to  remain  in  the  incubator  for  one  and  a  half  to 
two  weeks  longer  the  typical  picture  of  a  tubercle-bacilli 
culture  will  be  obtained — that  is,  there  will  be  seen  upon 
the  agar  an  uneven,  greyish-white,  dry,  lustreless  mass, 
which  is  made  up  of  flakes,  nodules,  and  small  scales  (Fig. 
291).  The  colonies  consist  of  variously  interlacing  strings 
of  bacteria  clinging  together  (Fig.  292).  Tubercle  bacilli 
also  thrive  in  bouillon  to  which  three  to  five  per  cent,  of 
glycerine  has  been  added,  and  they  have  even  been  cul- 
tivated upon  slices  of  potato  (made  alkaline)  which  were 
kept  from  drying  by  fusing  together  the  open  end  of  the 
glass  tube  containing  them  (Globig,  Roux). 

The  tubercle  bacilli  retain  their  virulence,  though  cul- 
tivated in  artificial  nutritive  media,  for  a  long  time. 
Koch  has  made  pure  cultures  of  these  bacilli  grow  in  a 
test  tube  for  more  than  nine  years,  and  he  has  observed 
only  a  slight  diminution  of  their  virulence.  The  tuber- 
cle bacilli  must  be  kept  from  the  light,  as  in  direct  sun- 
light they  perish  in  a  few  minutes  or  hours,  according 
to  the  thickness  of  the  culture.  The  dispersed  daylight 
acts  more  slowly. 

Toxine  of  Tubercle  Bacilli. — Koch,  Prudden  and  oth-  Fio.  291.— Linear  cul- 
ers  have  attempted  to  find  in  the  pure  cultures  of  the  ture  oj ^^^^^^^^^^^  ba- 
tubercle  bacillus  obtained  from  man  the  active  principle  agar  5  weeks  old. 
(toxine)  which  causes  the  morbid  conditions  associated 
wtih  tuberculosis.  According  to  the  discoveries  of  Prudden  and  Hodenpyl, 
the  poisonous  svibstances  are  not  found,  as  in  many  other  species  of  fungi,  in 
the  nutritive  medium,  but  they  are,  analogous  to  Buchner's  bacterial  protein, 
fixed  to  the  bodies  of  the  bacilli  in  an  extremely  resistant  form.  Their 
sojourn  in  the  living  body  does  not  change  them  for  a  long  time.  Complete 
recovery  from  tuberculosis  is  not  obtained  by  the  death  of  the  tubercle 
bacilli,  but  the  tubercular  foci  containing  the  dead  bacilli  must  likewise  be 
done  away  with  or  the  tubercular  poison  itself  rendered  harmless. 

Thomas  Weyl  has  isolated  a  highly  poisonous  substance— toxomucin 
—from  cultures  of  tubercle  bacilli.  According  to  Maffucci,  the  toxic  sub- 
stance formed   by  tubercle  bacilli  only  acts  after  the  lapse  of  a  long  period 


410 


INFLAMMATION   AND   INJURIES. 


of  time,  and  animals,  such  as  guinea-pigs,  inoculated  with  this  poison  die  of 
marasmus.  Richet  and  Hericourt  have  obtained  from  tubercular  cultures  a 
toxine  which  has  a  toxic  effect  upon  tubercular  rabbits,  but  none  at  all  upon 
healthy  ones. 

Certain  metabolic  products  which  are  dissolved  in  the  nutritive  media,  in 
a  glycerine-peptone  solution,  for  instance,  have,  according  to  Scholl,  a  cura- 
tive effect  upon  the  tubercular  process  when  injected  subcutaneously.  The 
tuberculin  isolated  by  Robert  Koch  is  described  on  page  421. 

Staining  of  Tubercle  Bacilli. — Different  methods  have  been  recommended 
for  staining  tubercle  bacilli.  The  examination  of  sputum  for  tubercle  bacilli 
is  as  follows  :  A  portion  of  one  of  the  ordinary  yellow,  tenacious  lumps  is 
taken  from  a  mass  of  sputum,  transferred  to  a  cover  glass,  upon  which  is 
then  placed  a  second  cover  glass,  and  the  material  to  be  examined  is  pressed 
between  them.  The  cover  glasses  are  then  removed  from  one  another,  al- 
lowed to  dry  in  the  air,  and  passed  three  times  through  a  flame.     While  the 

cover  glass  is  held  by  thumb 
forceps,  a  drop  of  carbolised 
fuchsin  is  placed  upon  it, 
the  preparation  is  held  a 
moment  over  the  flame,  and 
this  procedure  is  repeated 
several  times,  fresh  stain- 
ing solution  being  added  if 
necessary.  Then  the  stain 
is  washed  off  with  distilled 
water.  The  parts  surround- 
ing the  bacteria  are  decol- 
ourised with  fifteen  to  twen- 
ty i^er  cent,  nitric  acid  by 
moving  the  cover  glass  back 
and  forth  a  few  moments  in 
the  latter  until  the  deep-red  preparation  becomes^  greenish  blue.  Then  the 
dissolved  fuchsin  is  washed  away  in  seventy-per-cent.  alcohol,  and  the  prep- 
aration is  rinsed  in  distilled  water  and  re-stained  with  methylene  blue,  by 
which  everything  is  coloured  blue  except  the  bacilli,  which  still  remain  red. 
After  washing  in  water  the  preparation  can  be  examined  immediately,  or  it 
may  be  dxied,  and  mounted  in  Canada  balsam. 

Of  the  other  methods  of  staining  I  should  mention  particularly  B. 
Frankel's,  which  is  the  best  of  the  remaining  ones,  and  can  be  quickly  car- 
ried out  (staining  with  hot  carbolised  fuchsin,  then  decolourising  and  counter- 
staining  in  a  solution  of  fifty  parts  water,  thirty  parts  alcohol,  twenty  parts 
nitric  acid,  and  methylene  blue  to  saturation,  washing  in  water).  Gramas 
method  is  also  useful.  By  the  above-mentioned  rules  a  stain  can  be  given  to 
sputum,  faeces,  pus  from  a  wound,  samples  of  pure  cultures,  etc.  The  stain- 
ing of  a  section,  and  consequently  of  the  tubercle  bacilli  in  the  tissues,  is 
done  in  essentially  the  same  manner  (for  instance,  immersion  for  one  hour 
in  carbolised  fuchsin,  decolourising  in  dilute  [ten-per-cent.]  nitric  acid  for 
about  one  half  to  one  minute,  washing  in  seventy-per-cent.  alcohol,  counter- 
staining  in  methylene  blue  for  two  to  three  minutes,  dehydrating  in  absolute 


Fig.  202. — Colonies  of  tubercle  bacilli  upon  coagulated 
Vjlood-serum. 


j583.]  TUBERCULOSIS.  4I1 

alcohol,  clarifying  in  oil,  and  mounting  in  Canada  balsam).  Ehrlich's  aque- 
ous aniline-dye  solutions  are  also  much  used  for  sections  and  cover-glass 
preparations  (at  ordinary  temperatures  the  object  is  immersed  for  at  least 
twelve  hours  in  Ehrlich's  solution  [aniline-water,  fuchsin,  or  gentian  violet], 
at  higher  temperatures  for  a  shorter  time,  then  for  a  few  seconds  it  is  washed 
in  twenty-five-per-cent.  nitric  acid,  and  for  several  minutes  in  sixty-percent, 
alcohol,  then  double  stained  in  Bismarck-brown  or  a  methylene- blue  solu- 
tion, depending  upon  whether  it  was  first  stained  with  violet  or  fuschin,  then 
washed  in  sixty-per-cent.  alcohol  and  dehydrated  in  absolute  alcohol,  clari- 
fied in  oil  of  cedar,  and  mounted  in  Canada  balsam). 

Transmission  of  Tuberculosis  to  Animals.— The  transmissibility  of  tubercu- 
losis to  animals  by  inoculation,  by  intravenous  injection,  and  by  allowing 
them  to  eat  and  inhale  tuberculous  substances  had  been  proved  by  Klencke, 
in  1843,  before  Koch's  epoch-making  experiments  had  been  made.  Villemin 
(1865-'68)  was  the  first  to  demonstrate  by  systematic  exjieriments  that  tuber- 
culo.sis  can  be  ti-ansmitted  from  mau  to  animals,  and  from  animal  to  animal. 
These  experiments  were  then  repeated  with  positive  results,  particularly  by 
Chauveau,  Cohnheim,  Klebs,  and  others.  Then  Robert  Koch  showed  that 
tuberculosis  could  only  be  transmitted  to  animals  by  inoculation,  by  intra- 
venous injection,  and  by  inhalation  when  the  material  employed  contained 
tubercle  bacilli.  In  the  first  place,  Robert  Koch  repeated  many  times  success- 
fully the  inoculation  experiments  which  had  been  performed  upon  guinea- 
pigs,  rabbits,  etc.,  with  portions  of  tubercular  tissue  (nodules  of  miliary 
tuberculosis,  tubercular  pus,  phthisical  sputum,  fungous  matter  from  joints, 
lupus,  portions  of  scrofulous  glands,  nodules  of  bone  tuberculosis).  He  then 
employed  in  a  great  number  of  transmission  experiments  pure  cultures  of 
tubercle  bacilli,  and  by  inoculating  these  into  the  subcutaneous  tissue,  into 
the  anterior  chamber  of  the  eye,  and  by  injecting  them  into  the  peritoneal 
cavity  and  into  the  veins,  and  by  causing  them  to  be  inhaled,  he  produced 
true  tuberculosis,  with  its  characteristic  bacilli,  which  could  be  again  and 
again  successfully  transmitted  to  other  animals.  So  Koch  has  furnished  in 
the  most  convincing  manner  the  indisputable  proof  that  tuberculosis  is 
caused  by  specific  bacilli.  Koch's  admirable  work  will  be  found  in  the 
Mittheilungen  des  Kaiserlichen  Gesundheitsamtes,  1884. 

Almost  at  the  very  same  time  that  Koch  published  his  work  upon  the 
etiology  of  tuberculosis,  Baumgarten,  independently  of  Koch,  had  likewise 
found  bacilli  in  the  tubercles  produced  in  rabbits  by  inoculation,  but  he  did 
not  make  cultures  and  inoculations  with  them. 

All  animals  are  not  equally  susceptible  to  tubercle  bacilli.  Guinea-pigs, 
rabbits,  and  ruminants  have  a  pronounced  predisposition  for  tuberculosis, 
while  dogs,  rats,  and  white  mice  are  immune  from  it.  It  is  well  known  that 
man  shows  great  variations  in  susceptibility  to  the  poison  of  tuberculosis. 

Tuberculosis  of  Cattle.— The  tuberculosis  of  cattle,  in  which  small  and 
lai'ge  nodules  are  formed  even  reaching  the  size  of  a  walnut  or  potato,  is, 
according  to  recent  investigations,  identical  with  the  tuberculosis  of  man, 
and  the  presence  of  tubercle  bacilli  has  likewise  been  demonstrated.  Inocu- 
lation experiments  have  also  given  corresponding  results.  By  the  ingestion 
of  meat  and  milk  containing  tubercle  bacilli  from  tubercular  cows  (particu- 
larly those  ^vith  local  tubercular  disease  of  the  udder),  tuberculosis  may  easily 


412  INFLAMMATION   AND   INJUIRES. 

be  caused  in  man.  If  boiled,  the  virulence  of  infected  milk  is  destroyed  ;  its 
poisonous  character  may  be  weakened  by  diluting-  it  with  milk  which  is  free 
from  bacteria  (Bollinger). 

Pseudo-Tuberculosis. — Eberth  has  described  a  pseudo-tuberculosis  of 
guinea-pigs.  Changes  simulating  tuberculosis  are  found  particularly  in  the 
abdominal  organs,  especially  in  the  liver,  and  to  a  less  extent  in  the  lungs. 
Some  of  the  nodules  present  the  appearance  of  miliary  tubercles,  others  of 
small  abscesses.  In  the  centre  of  the  nodules  collections  of  micrococci  are 
found,  and  the  nodules  themselves  appear  microscopically  either  as  spots 
of  coagulation  necrosis,  surrounded  by  a  zone  of  leucocytes,  or  as  collections 
of  pus.  The  tuberculose  zoogloeique  of  Malassez  and  Vignal  is  probably  iden- 
tical with  this  pseudo-tuberculosis.  Eberth  also  observed  a  tubercle-like  dis- 
ease— a  pseudo-tuberculosis — in  rabbits,  and  he  found  the  micro-organisms  to 
be  small,  short  I'ods,  double  the  width  of  tubercle  bacilli  antl  rounded  at  the 
ends,  forming  chains  made  up  of  shorter  or  longer  segments,  which  were 
either  placed  side  by  side  or  twisted  together  in  groups  and  collected  in  thick 
clusters.  Eppinger  found  a  cladothrix  form  to  be  the  excitant  of  pseudo- 
tvdjerculosis  in  man. 

The  Tubercle  Bacillus  of  Birds.— The  weakened  (attenuated)  or  virulent 
tubercle  bacillus  of  birds,  cultivated  in  a  liquid  of  slight  nutritive  powers, 
furnishes  substances,  according  to  Courmont  and  Dor,  by  means  of  which 
rabbits  can  be  made  immune  from  the  effects  of  inoculation  with  the  tubercle 
bacillus  of  man. 

Combination  of  Tuberculosis  with  Carcinoma  and  Syphilis.— In  rare  cases 
there  has  been  observed  the  simultaneous  occurrence  of  carcinoma  and  tuber- 
culosis in  the  same  portion  of  the  body ;  for  instance,  an  eruption  of  tubercles 
may  be  found  in  the  neighbourhood  of  a  carcinoma  of  the  stomach  or  larynx. 
In  such  instances  the  tubercle  bacilli  have  gained  access  to  the  sui-rounding 
tissues  through  the  carcinomatous  ulceration  (Zenkel,  Hofmokl,  and  others). 
The  simultaneous  occurrence  of  syphilis  and  tubei'culosis  is  also  interesting  ; 
the  syphilitic  product,  for  example,  may  gradually  take  on  a  tubercular  char- 
acter from  the  lodgement  of  tubercle  bacilli  (Eisenberg,  Leloir).  In  conse- 
quence of  such  a  mixed  tubercular-syphilitic  infection,  there  will  be  observed 
corresponding  affections — for  instance,  of  the  lymphatic  glands  and  skin — 
which  will  only  partially  disappear  under  antisyphilitic  treatment. 

Origin  of  Tuberculosis  in  Man. — ^Ta  the  first  place,  individual  pre- 
disposition, which  may  be  congenital  or  acquired,  is  of  particular  im- 
portance in  the  acquirement  of  tuberculosis  by  man.  This  predisposi- 
tion is  due  to  general  constitutional  conditions  and  to  local  changes  in 
the  tissues,  and  especially  to  variations  in  the  metabolism  of  the  tis- 
sues exhibited  by  some  individuals,  as  well  as  a  change  in  the  ir- 
ritability of  the  cells.  Foremost  in  this  category  stands  scrofula, 
a  congenital  or  acquired  constitutional  disturbance  of  nutrition.  Cli- 
matic and  other  conditions  peculiar  to  certain  regions  are  also  of  great 
importance.  In  many  places,  such  as  certain  high  resorts  or  regions 
where  lime  indastries  exist,  tuberculosis  is  almost  unknown. 


§  83.J  TUBERCULOSIS.  4I3 

The  tubercle  bacilli  or  their  spores,  whose  existence  is  still  douljt- 
ful,  are  contained  in  the  atmospheric  air,  into  which  they  get  from  the 
excretions,  or  the  spntnm,  etc.  of  animals  or  man  alfected  with  tuber- 
cular disease.  Tubercle  bacilli  are  found  particularly  in  the  dust  or 
the  air  in  which  phthisical  sputum  has  op})ortuiiity  to  dry  and  be- 
come dispersed.  They  are  also  carried  about  by  flies  (Spillmann, 
Ilaushalter).  To  put  a  prophylactic  restraint  upon  tuberculosis  it  is 
advisable  lirst  of  all  to  introduce  cuspidors  into  more  general  use,  pro- 
vided with  a  solution  of  bichloride  of  mercury  (Cornet).  Healthy 
people  can  very  easily  become  infected  with  tuberculosis  by  constant 
contact  with  unclean  phthisical  individuals.  Tubercle  bacilli  are  taken 
into  the  body  chiefly  by  the  lungs;  they  also  are  taken  into  the  intes- 
tine with  the  food,  or  they  flnd  entrance  through  an  interruption  in  the 
continuity  of  the  skin,  through  fresh  wounds,  etc.  Tuberculosis  pro- 
duced by  inoculation  into  very  small  wounds  or  cutaneous  abrasions  is 
observed  particularly  on  the  hands  of  physicians,  students,  nurses, 
dead-house  attendants,  washerwomen,  etc.  According  to  Baumgarten, 
Tangl,  and  others,  the  bacilli,  as  the  result  of  their  growth  and  multi- 
plication, always  form  at  the  point  where  thej-  were  absorbed,  a  local 
tubercular  focus  of  inflammation.  They  may  also  gain  access  to  the 
circulation,  and  by  it  be  carried  into  the  internal  organs,  particularly 
the  lymph  glands  and  bones  (the  marrow).  The  tubercular  affection 
is,  at  the  outset,  always  purely  local  (Baumgarten,  Ponfick),  but  if  the 
poison  gets  into  the  general  circulation  and  so  is  distributed  through- 
out the  system,  general  miliary  tuberculosis,  or  a  flooding  of  the  body 
as  it  were  with  bacilli,  can  take  place. 

Local  tubercular  disease  originates  with  preference  in  the  places 
where  the  tubercle  bacilli  easily  find  lodgement  and  are  not  mechanic- 
ally swept  away,  as  in  the  lungs,  the  lyinph  glands,  in  the  capillaries  of 
the  bone  marrow  which  have  no  walls,  iji  terminal  vessels,  and  espe- 
cially in  blood. extravasations.  According  to  Robert  Koch,  tuberculosis 
in  man  originates  most  frequently  in  the  lungs.  It  is  a  matter  of  im- 
portance for  the  surgeon  to  know  that  tuberculosis  of  the  skin  and 
lymph  glands  can  result  from  scratches,  cutaneous  eruptions,  and  ulcers 
in  the  skin,  Czerny  saw  two  cases  which  had  been  inoculated  with 
tuberculosis  by  skin  transplantation.  Embolic  tuberculosis  of  different 
organs,  particularly  the  bones  and  joints,  frequently  originates  from 
tubercular  bronchial  glands. 

Extension  of  Tubercular  Inflammation. — The  extension  of  the  tubercu- 
lar inflammation,  which,  as  we  have  said,  is  at  the  outset  purely  local,  is 
dependent  upon  the  multiplication  of  the  bacilli.     The  extension  either 

proceeds  steadilv  by  contiguitv,  or  the  wandering  cells  carrv  the  bacilli 
27    "  " 


414  INFLAMMATION   AND   INJURIES. 

into  the  adjoining  parts  and  there  form  new  foci,  which  either  re- 
main isolated  or  gradually  coalesce  with  the  primary  focus.  By  the 
entrance  of  living  bacilli  into  the  circulation  (blood,  lymph)  the  tuber- 
cular inflammation  may  be  distributed  throughout  the  entire  body. 
We  observe  an  extension  of  the  tubercular  inflammation  by  contiguity 
when,  for  example,  a  tubercular  inflammation  of  the  bone  marrow 
breaks  through  the  bone  and  infects  a  neighbouring  joint.  In  a  simi- 
lar manner  the  large  serous  cavities  become  diseased,  usually  by  direct 
extension  of  the  tubercular  inflammation  from  one  of  the  organs  that 
form  their  walls  (Weigert).  Thus  tubercular  pleurisy  originates,  in 
the  majority  of  instances,  from  a  small  pulmonary  focus  extending  to 
the  pleura,  or  from  tubercular  disease  of  the  vertebra?,  ribs,  or  lymph 
glands.  Tuberculosis  of  the  peritoneum  is  most  frequently  observed  in 
conjunction  with  a  tuberculosis  of  the  intestine,  the  female  organs  of 
generation,  etc.  Deposition  of  the  poison  directly  from  the  blood  into 
the  serous  cavities  seldom  takes  place.  Occasionally  the  extension  of  the 
tuberculosis  can  be  traced  along  the  lymph  channels.  In  such  cases 
there  will  be  observed  a  corresponding  formation  of  nodules  in  the 
course  of  the  lymphatic  vessels.  From  the  lymph  channels  the  poison 
passes  into  the  lymph  glands,  then  through  the  thoracic  duct  into  the 
blood-vessels ;  or  it  may  break  into  a  vein  directly,  and  in  such  cases 
cause  a  general  distribution  of  the  bacilli  all  through  the  system,  so 
that  nodules  occur  everywhere  (general  miliary  tuberculosis),  and  then 
death  usually  follows  in  a  short  time. 

Tubercular  Systemic  Poisoning. — In  fourteen  cases  of  general  miliary 
tuberculosis,  Weigert,  by  carefully  examining  the  veins,  was  able  thii*- 
teen  times  to  demonstrate  the  place  where  the  poison  broke  through 
into  the  veins,  or  into  the  thoracic  duct,  in  the  form  of  tubercular 
thrombi.  Not  infrequently  there  is  an  extensive  formation  of  tuber- 
cles in  the  walls  of  the  vessels.  The  bacilli  occasionally  lodge  in  the 
intima  of  the  thoracic  duct  itself.  In  such  cases  there  is  observed  a 
cheesy  ulceration  of  the  intima  of  the  duet  (Ponfick). 

Demonstration  of  Tubercle  Bacilli.— The  demonstration  of  the  tubercle 
bacilli  is,  as  we  have  remarked,  of  the  greatest  importance  for  diagnostic  pur- 
poses, particularly  when  found  in  the  blood  in  general  tuberculosis,  in  the 
sputum  in  tuberculosis  of  the  respiratory  tract,  in  the  evacuations  from  the 
bowel  in  intestinal  tuberculosis,  in  the  urine  in  genito-urinary  tuberculosis, 
and  in  the  pus  in  tubercular  disease  of  bones,  joints,  and  soft  parts.  The 
bacilli  can  be  most  easily  demonstrated  in  the  sputum  when  they  find  a 
medium  favourable  for  their  nutrition,  and  can  keep  on  multiplying  second- 
arily. According  to  Robert  Koch,  the  bacilli  are  particularly  apt  to  be  found 
whei-e  the  tubercular  process  is  in  its  inception,  the  cheesy,  suppurating 
products,  as  a  general  rule,  containing  but  few  bacilli.     Very  often  the  tu- 


g83.]  TUBERCULOSIS.  415 

borclo  bacilli  cannot  he  demonstrated  in  tubercular  pns;  nevertheless  guinea- 
pipfs  iuocuJaled  with  (his  i)us  will  die  of  tuberculosis  (Tavel).  The  giant 
(•ells,  in  a  process  which  lias  lasted  a  long  time,  will  contain,  for  the  most 
pai't,  t)nly  a  few  bacilli. 

Termination  of  the  Tubercular  Inflammation. — Wlicrever  they  may 
occur,  botli  the  nodules  and  the  diffuse  tubercular  infiltration  disinte- 
grate and  undergo  chees}'  degeneration.  In  this  way,  particularly  in 
the  skin  and  mucous  membranes,  tubercular  ulcers  are  forme<l  with  a 
cheesy  or  caseous  base  after  the  inflammatory  processes  have  broken 
through  externally.  In  other  cases,  particularly  in  tuberculosis  of  the 
bones  and  joints,  extensive  suppuration  occurs.  The  j)us  in  the  latter 
process  has  characteristic  properties ;  it  is  usually  thin,  and  contains 
cheesy  masses.  Occasionally,  as  in  tubercular  inflammation  of  the  verte- 
brae, extensive  abscesses  develop,  which  gradually  sink  downwards  along 
the  connective-tissue  spaces.  These  are  called  congestion  or  c^ld  abscesses 
(see  Tuberculosis  of  Bone).  In  the  bones  and  joints  the  disturljances 
excited  by  the  tuberculosis,  as  we  shall  see  later  on,  are  very  considerable. 

The  tubercular  suppuration  is  mainly  due  to  the  tubercle  bacilli, 
though  in  many  cases  there  is  a  mixed  infection  with  pus  cocci — the 
staphylococcus  and  streptococcus  (Garre,  Tavel). 

A  reactive  inflammation  usually  takes  place  around  the  tubercular 
focus,  encapsulating  the  latter,  the  organism  trying  in  this  way  to  pro- 
tect itself  from  further  infection.  The  single  foci  of  tubercular  in- 
flammation may  entirely  heal,  and  they  do  this  the  more  readily  the 
smaller  they  are  and  the  earlier  and  more  completely  they  are  removed 
by  operative  measures.  Spontaneous  healing  of  tuberculosis  is  due  to 
a  reactive  inflammation  in  the  neighbourhood  of  the  tubercular  inflam- 
mation. The  cheesy  masses  become  absorbed  or  encrusted  with  the 
salts  of  lime,  the  bacilli  gradually  die,  and  firm  connective  tissue  takes 
the  place  of  the  tubercular  material.  But  there  is  always  the  danger 
that  the  tubercular  inflammation  may  break  out  afresh  as  long  as  bacilli 
capable  of  development  remain  enclosed  in  the  original  focus  of  infec- 
tion. The  bacilli,  or  rather  their  spores,  appear  to  have  great  powers 
of  resistance,  which  explains  why  tubercular  inflammation  recurs  with 
such  extraordinary  frequency.  The  greater  the  number  of  the  foci 
of  disease,  so  much  the  more  improbable  is  the  recovery.  All  too 
often  the  latter  is  only  apparent  or  temporary,  and  then  suddenly  the 
disease  appears  afresh.  Every  individual  who  has  shown  his  suscepti- 
bility to  the  poison  of  tuberculosis  by  having  had  one  attack  of  the 
disease  is  always  in  danger  of  a  new  outbreak. 

Inheritance  of  Tuberculosis. — An  important  question  for  the  physician  is 
whether  tuberculosis  can  be  inherited — that  is,  whether  the  tubercle  bacillus 


416  INFLAMMATION  AND   INJURIES. 

is  transmitted  from  the  parents  to  the  foetus,  either  at  the  time  of  conception 
or  durinj^  its  intra-uterine  life. 

Transmission  of  the  Tubercle  Bacillus  from  the  Mother  to  the  Foetus. — 
Congenital  tuberculosis  in  man  has  not  yet  been  observed  with  certainty,  as 
far  as  I  know,  and  consequently  there  is  a  tendency  not  to  admit  the  possi- 
bility of  the  inheritance  of  the  poison  of  tubercular  disease  as  of  other 
hereditary  infectious  diseases.  But  it  is  generally  accepted  that  the  dis- 
position or  the  tendency  to  tuberculosis  is  inherited  :  that  is.  there  are 
transmitted  certain  ])eculiarities  of  the  organism — for  instance,  a  peculiar 
quality  of  the  circulatory  liquids,  a  certain  irritability  of  the  cells,  etc. — in 
consequence  of  which  the  organism  .under  consideration  forms  a  particularly 
favourable  soil  for  the  tubercle  bacillus.  Eecent  expeiiments  and  clinical 
observations  upon  animals  prove,  however,  the  actual  occurrence  of  a  con- 
genital tuberculosis  in  animals.  Johne,  Hertvig  and  Csokor  found  tubercle 
bacilli  in  the  foetus  of  cattle.  Koubassoif  infected  pregnant  guinea  pigs  with 
tubercle  bacilli  ;  both  the  mother  and  the  foetus  became  tubercular,  and 
tubercle  bacilli  were  found  in  each.  Landouzy  and  Martin  have  also  per- 
formed experiments  which  speak  for  the  occurrence  of  congenital  tubercu- 
losis, and  Weigert  found  tubercle  bacilli  in  the  spermatozoa  of  tubercular 
men.  Hence  foetal  tuberculosis  might  originate  in  man,  particularly  if  there 
already  existed  tuberculosis  of  the  genito-urinar\'  apparatus,  and  if  bacilli 
were  pre.sent  in  the  blood  of  the  father.  It  is  well  known  that  children  of 
tubercular  parents  easily  contract  tuberculosis  after  birth,  and  hitherto  it 
has  been  believed  that  tuberculosis  always  originates  after  birth,  because 
the  children  in  question  inherit  a  jn-edisposition  for  it  and  are  exposed  to 
a  marked  extent  to  infection  by  contact  with  their  parents.  I  have  no  doubt 
that  some  cases  of  tuberculosis  apparently  originating  after  birth  have 
already  begun  in  utero.  and  consequently  are  of  congenital  origin.  This  has 
been  recently  confirmed  by  observations  made  by  Birch-Hirschfeld.  He 
demonstrated  that  the  tubercle  bacillus  has  the  power  of  passing  through  the 
walls  of  the  vessels  from  the  maternal  into  the  foetal  circulation.  He  had  one 
case  of  a  twenty-three-year-old  woman  who  had  died  of  miliary  tuberculosis 
in  the  seventh  month  of  pregnancy.  In  the  placenta  there  were  found,  in 
the  intervillous  spaces  and  in  the  interior  of  the  vessels  of  the  villi,  many 
tubei'cle  bacilli  :  they  were  also  found  in  the  liver  of  the  foetus.  Inocula- 
tions made  with  ]X)rtions  of  the  foetal  organs  produced  tuberculosis  in  guinea- 
pigs.  Birch-Hirschfeld  still  holds  to  the  general  opinion  that  under  normal 
conditions  the  placenta  is  imxiervious  for  finely  divided  foreign  bodies  or 
micro-organism.s,  but  by  pathological  processes,  or  rather  by  the  lodgement  of 
micro-organisms,  this  filter  is  made  pervious.  The  bacilli,  as  it  were,  grow 
into  the  foetal  portion  of  the  placenta  in  the  same  way  that  the  anthrax 
bacilli  enter  the  pulmonary  vessels  after  the  inhalation  of  anthrax  spores 
which  Buchner  demonstrated  experimentally. 

Brief  Heview  of  Tubercular  Disease  in  the  Various  Tissues  and  Organs 
as  far  as  it  concerns  the  Surgeon. — Concerning  the  clinical  course  of 
tubercular  disease  in  the  various  organs  and  tissues  as  far  as  it  concerns 
the  surgeon,  the  following  brief  statement  will  suffice  : 
/ ,   Tuberculosis  of  the  Skin  and  Subcutaneous  Cellular  Tissue. — Tubercu- 


§83.]  TUBERCULOSIS.  41 7 

losis  of  the  external  cntaneous  covering  and  of  the  cellular  tissue  is  of 
frequent  occurrence.  The  so-called  lupus  (§  93,  Chronic  Inflaminations 
of  the  Skin)  is  a  special  form  of  tuberculosis  of  the  skin.  Lupus  occurs 
ahjne,  or  it  may  be  a  part  of  a  tubercular  constitutional  affection. 
Other  tubercular  ulcerations  of  the  skin  occur,  particularly  in  children 
and  young  individuals,  either  primary  or  secondary,  for  instance,  to 
tubercular  abscesses  of  the  lymph  glands  and  tubercular  bone  and  joint 
disease.  These  tubercidar  ulcerations  of  the  skin  usually  yield  readily 
to  surgical  treatment. 

T]ie^  so-called  'anatomical  tubercle,  verruca  necrogenica,  described 
in  §  70,  is  occasionally,  though  not  always,  a  true  tuberculosis  of  the 
sku). 

Primary  tuberculosis  of  the  panniculus  adiposus,  particularly  in 
young  children,  takes  the  form  of  firm,  flat,  subcutaneous  nodes,  which 
gradually  extend,  coalesce,  and  break  through  externally  after  the  skin 
has  necrosed.  In  other  cases  they  may  evince  a  preference  to  grow 
into  the  deeper  parts  beneath  the  more  or  less  uninjured  skin. 

Primary  tuberculosis  and  primary  tubercular  abscesses  of  the  deep 
intermuscular  spaces  and  connective  tissue  in  the  neighbourhood  of 
bones  and  joints  are  very  rare.  Tuberculosis  in  these  regions  is  usually 
secondary  to  tubercular  disease  of  the  bones,  joints,  and  lymph  glands. 
In  this  category  should  be  classed  the  congestion  abscesses — that  is,  the 
so-called  cold  abscesses  following  tubercular  disease  of  the  bones  or  the 
joints,  particularly  those  of  the  vertebral  column. 

Tubercular  abscesses  are  very  frequently  observed.  They  are  usu- 
ally enclosed  by  a  characteristic  greyish  or  yellowish-grey  membrane — 
the  so-called  abscess  membrane — containing  miliary  tubercles.  This 
membrane  can  be  easily  loosened  or  scratched  off  from  the  healthy 
adjoining  parts.  Only  in  rare  instances  is  there  seen  a  diffuse  spread- 
ing of  the  tubercular  inflammation  into  the  muscular  tissue.  The 
above-mentioned  abscess  membrane  is  only  observed  in  tuberculosis, 
and  is  consequently  of  diagnostic  importance.  It  is  lacking  in  syphilis, 
in  which,  in  general,  there  is  more  frequently  observed,  in  contradis- 
tinction to  tuberculosis,  a  diffuse  cheesy  degeneration  of  the' muscles, 
for  instance. 
^'  Tuberculosis  of  Mucous  Membrane — The  Tongue. — Amongst  tubercu- 
lar affections  of  the  exposed  mucous  membranes  there  is  observed,  a 
tuberculosis  of  the  tongue  which  sometimes  takes  the  form  of  a  partly 
torpid,  partly  fungous  ulceration,  and  at  others  of  a  deep-seated  node 
with  central  softening.  The  tubercular  ulcer  of  the  tongue,  with  an 
indurated  area  surrounding  it.  may  sometimes  be  mistaken  for  cancer, 
and  tubercular  nodes  have  a  similarity  to  syphilitic  gummata,    but 


418  INFLAMMATION  AND   INJURIES. 

tlieir  local  manifestations  and  the  whole  clinical  course  will,  in  the  ma- 
jority of  cases,  assure  the  correct  diagnosis.  In  two  cases  Yolkmann 
saw  the  entire  superficial  surface  of  tlie  tongue  covered  with  tubercular 
ulcers,  varying  in  size  from  that  of  a  pin-head  to  that  of  a  pea,  and 
between  them  miliary  tubercles  were  everywhere  visible.  The  great 
majority  of  patients  operated  upon  for  tuberculosis  of  the  tongue  sub- 
sequently die  of  pulmonary  tuberculosis ;  l)ut  still  some  complete  re- 
coveries have  been  recorded  even  in  individuals  strongly  predisposed 
by  heredity. 

''  Tuberculosis  of  the  Pharynx  and  Palate  occurs  mainly  in  tubercular 
children  at  the  age  of  puberty  and  soon  after,  in  the  form  of  ulcers  the 
size  of  a  pea  and  larger,  having  a  tendency  to  coalesce,  and  located  on 
the  palatine  arches,  the  posterior  wall  of  the  pharynx,  and  the  pos- 
terior surface  of  the  velum  palati.  Between  the  ulcers  there  do  not 
often  fail  to  be  miliary  nodules,  which  are  visible  when  the  illumina- 
tion is  sufficient.  Tuberculosis  of  the  pharynx  and  palate  is  very  apt 
to  be  confused  with  syphilis.  Jn  the  differential  diagnosis  it  is  to  be 
noted  that  syphilis  produces  more  loss  of  substance,  while  tuberculosis 
is  more  apt  to  give  rise  to  extensive  ulcerating  surfaces  which  have  a 
tendency  to  shrink  and  contract.  In  this  condition  permanent  recov- 
eries have  also  undoubtedly  been  obtained,  but  the  majority  of  the 
patients  die  of  pulmonary  tuberculosis. 

U .  Nose. — Tuberculosis  of  the  nasal  mucous  membrane  (ozsena  tuber- 
cularis)  occurs  in  the  form  of  a  primary  tubercular  ulceration  of  the 
mucous  membrane,  or  secondary  to  primary  tuberculosis  of  the  bones, 
particularly  the  upper  jaw. 

i ,  Lips. — Severe  tubercular  ulcerations  occasionally  make  their  appear- 
ance upon  the  lips. 

(r  .  Rectum. — Some  fistulse  of  the  rectum  are,  as  the  ancient  physicians 
well  knew,  tubercular  in  character.  The  tubercular  rectal  fistula  is 
characterised  by  a  tendency  to  the  formation  of  fungous  granulations, 
by  an  extensive  lifting  up  of  the  mucous  membrane  from  the  under- 
lying parts,  undermining  of  the  skin,  and  by  the  formation  of  abscesses 
with  sinuses.  The  prognosis  of  tubej^ular  rectal  fistula  is  very  un- 
favourable. 

^j  Intestine. — Tubercular  perityphlitis  occurs  after  perforation  of  a 
tubercular  intestinal  ulcer.  It  gives  rise  to  large  tubercular  abscesses, 
and  yet  patients  who  have  them  are  often  otherwise  entirely  well. 
'{,  Genito-urinary  Tuberculosis. — It  has  been  my  experience  to  find  that 
tuberculosis  of  the  genito-urinary  apparatus  runs  a  particularly  unfa- 
vourable course,  sometimes  with  great  rapidity.  Tuberculosis  of  the 
testicle  and  epididymis — originating  either  primarily  or  secondarily  to 


t;83.]  TUBERCULOSIS.  419 

tuberculosis  of  the  vas  deferens  or  the  genito-urinary  apparatus — usually 
occurs  in  young  or  niiddle-aged  men,  and  even  old  men  are  not  exempt. 
In  general  it  is  best,  as  soon  as  possible,  to  remove  the  tubercular  focus 
in  order  to  prevent  the  process  frotn  involving  the  other  testicle  or  the 
spermatic  cord,  prostate,  and  bladder.  Tuberculosis  of  the  spermatic 
cord  is  characterised  by  an  even  thickening  or  a  nodular  swelling  in 
the  course  of  the  vas  deferens.  Tuberculosis  of  the  bladder,  urethra, 
and  kidneys  is  very  typical,  and  belongs  to  the  severest  of  the  tuber- 
cular diseases.  Tuberculosis  of  the  bladder  has  hitherto  resisted  all 
attempts  to  cure  it.  The  demonstration  at  an  early  period  of  tubercle 
bacilli  in  the  urine  is  of  great  practical  importance.  For  tuberculosis 
of  the  kidney  or  its  pelvis,  it  is  best,  at  as  early  a  stage  as  possible,  to 
undertake  operative  treatment  iu  the  form  of  nephrotomy  or  nephrec- 
tomy (Madehmg).  I  must  refer  the  reader  to  my  text-book  of  special 
surgery  and  to  the  text-books  on  gynecology  for  tuberculosis  of  the 
penis,  vagina,  and  uterus.  In  rare  instances  inoculation  with  tubercu- 
losis may  take  place  on  the  external  genitals  as  a  result  of  coitus 
(Kraske,  Schmidt).  Tuberculosis  of  the  mannna  is,  according  to  Bill- 
roth, Volkmann,  and  others,  very  rare,  and  its  diagnosis  is  only  possi- 
ble in  the  later  stages.  In  every  case  of  tuberculosis  of  the  breast  the 
entire  mamma,  with  the  corresponding  axillai-y  lymphatic  glands, 
should  be  removed. 

Tuberculosis  of  Bones,  Joints,  and  Tendon  Sheaths.— I  shall  refer  to  tu- 
berculosis of  bones,  joints,  and  tendon  sheaths  in  the  paragraphs  upon 
these  subjects.  It  need  only  be  stated  here  that  tuberculosis  of  bones 
and  joints  is  very  common,  and  that  the  true  caries  of  bones  and  joints 
— the  so-called  funs^ous  inflammation  of  bones  and  joints — is  with  few 
exceptions  true  tuberculosis.  Tuberculosis  of  bones  and  joints  origi- 
nates very  frequently  as  a  result  of  a  traumatism.  The  tubercular 
joint  inflammations  are,  particularly  in  children,  secondary  in  nature, 
as  they  are  most  frequently  due  to  an  extension  of  the  process  from  the 
bones.  The  tuberculosis  of  bones  occurs  chiefly  as  a  tubercular  osteo- 
myelitis, which  very  frequently  leads  to  the  formation  of  large  cold 
abscesses.  Tuberculosis  of  the  tendon  ■  sheaths  manifests  itself  some- 
times as  a  diffuse  fungous  disease  and  sometimes  in  the  form  of  sepa- 
rate nodes. 

Lymph  Glands.— Tuberculosis  of  the  lymph  glands  is  exceedingly 
common,  particularly  in  the  neck.  Areas  of  characteristic  cheesy  de- 
generation and  suppurative  softening  develop  either  primarily  in  con- 
junction with  a  scrofulous  hyperplasia  of  the  glands,  or  secondary  to 
tuberculosis  of  the  lymph  district  in  question.  It  is  of  very  great 
practical   importance  that   this  glandular  tuberculosis  should  receive 


420  INFLAMMATION  AND  INJURIP:S. 

"operative  treatment  at  as  early  a  stage  as  possible,  because,  if  the  poi- 
son passes  into  the  circulation,  general  miliary  tuberculosis  may  readily 
follow. 

Diagnosis.— The  diagnosis  of  tuberculosis  is  rendered  certain  when 
it  is  possible  to  demonstrate  the  presence  of  tubercle  bacilli,  when  inoc- 
ulation is  successful,  and  the  microscopic  examination  of  the  tissues  re- 
veals the  above-described  characteristic  structure  of  the  tubercles. 

Prognosis  of  Tuberculosis. — We  have  already  sufficiently  outlined 
the  prognosis  of  tuberculosis.  Even  in  surgical  tuberculosis,  though 
radical  operative  treatment  may  be  adopted,  a  permanent  cure  is  not 
so  often  observed  as  many  enthusiasts  believe  ;  but  the  sooner  the 
tubercular  focus  is  removed,  the  smaller  it  is,  etc.,  so  much  the^more 
ground  may  we  have  for  expecting  a  permanent,  complete  cure.  But, 
as  has  been  said,  there  is  always  the  danger  of  a  fresh  recurrence  of 
the  disease  even  years  later.  For  children,  the  prognosis,  in  general,  is 
better  than  for  adults ;  we  often  enough  see  spontaneous  recovery  take 
place  in  them  from  the  most  severe  bone  and  joint  tuberculosis.  But 
we  know,  from  the  statistics  of  Billroth  and  others,  that  individuals 
who  have  suffered  in  their  youth  from  tubercular  disease  of  bone  do 
not  usually  attain  an  advanced  age. 

Treatment  of  Tuberculosis. — For  the  treatment,  I  must  refer  the 
reader  to  the  treatment  of  tuberculosis  in  the  different  tissues.  Only 
the  following  brief  summary  will  be  giv^en  here:  The  treatment  of 
surgical  tuberculosis,  particularly,  for  instance,  of  bones  and  joints, 
until  a  few  years  ago  was  very  largely  operative.  At  present  the 
treatment  is  taking  more  of  a  conservative  direction.  The  operative 
treatment,  which  used  to  be  so  energetically  pursued,  is  in  part, 
and  with  the  best  results,  becoming  supplanted  by  a  more  chem- 
ical treatment,  and  chiefly  by  the  aseptic  injection  of  sterilised  ten-per- 
cent, iodoform  oil  or  iodoform  glycerine  (P.  Bruns).  To  avoid  iodo- 
form intoxication,  it  is  best  to  sterilise  olive  oil  or  glycerine  and  iodo- 
form separately,  by  heating  them  at  a  temperature  of  100°  C.  in  the 
sterilising  apparatus,  and  then  to  make  with  them  a  ten-  to  twenty-per- 
cent, mixture.  Iodoform,  in  fact,  appears  to  have  a  direct  antitul^er- 
cular  action,  as  proved  by  the  experiments  of  Baumgarten,  Troje,  and 
Tange.  Arsenic,  carbolic  acid,  balsam  of  Peru,  lime  with  phosphoric 
acid,  and  oil  of  cloves  (1  to  10  of*  olive  oil),  etc.  (Buchner,  Hueter,  etc.), 
have  also  been  recommended  for  the  treatment  of  surgical  tuberculosis. 
Landerer  recommends  the  intravenous  injection  of  a  cinnamic-acid 
emulsion,  which  must  be  first  rendered  alkaline  according  to  the  fol- 
lowing formula :  Acid,  cinamylici  5'0,  ol.  amygdal.  lO'O,  vitelli  ovi 
unius,  sol.  natr.  chlor.  (0'7  per  cent.)  q.  s.  ut  f.  emuls.,  lOO'O. 


§83.]  TUBERCULOSIS.  421 

Arsenic  has  been  reconiniendud  by  Buclmcr  both  h:)cally  and  inter- 
nally, lie  believes  that  this  remedy  greatly  increases  the  powers  of  re- 
sistance of  the  body,  or  rather  of  the  cells.  P.  Bruns  and  others  have 
obtained  no  satisfactory  results  from  the  injection  of  Kolischer's  phos- 
phate-of-lime  solution  (calc.  phosphor,  neutr.  5*0,  aq.  dest.  50"0,  acid, 
phosphor,  q.  s.  ad.  solut.  perfect,  tiltra,  adde  acid,  phosphor,  dil.  0'6,  aq. 
destil.  q.  s.  ad.  lOO'O,  and  inject  about  10  to  12  to  2-4  c.cm.).  Similar  un- 
satisfactory results  wore  obtained  with  Kolischer's  lime-f^auze  packing. 
The  gauze  is  imjiregnatod  with  the  above  solution  and  contains  ten 
times  its  weight  of  dilute  pliusphoric  acid. 

A.  Bier  has  obtained  reniarkaljle  success  in  tuberculosis  of  the 
extremities  by  employing  permanent  congestive  hyperaimia,  brought 
about  by  the  application  of  a  rul)ber  tourniquet  on  the  proximal  side 
of  the  tubercular  disease.  This  method  of  treatment  was  suggested  to 
Bier  by  the  well-known  fact  that  the  congested  lung  is  immune  from 
tuberculosis. 

Especially  iodine,  arsenic  and  lactic  acid  have  been  used  internally. 
The  treatment  of  the  general  condition  of  the  patient  is  very  impor- 
tant, and  the  course  of  tuberculosis  is  influenced  very  markedly  by 
good  food  and  good  air  and  by  a  strengthening  mode  of  life  thoroughly 
carried  out.  It  is  also  a  good  plan  to  employ  baths,  sea  bathing,  sea 
voyages,  yearly  sojourns  in  southern  climates  (Egypt,  Madeira,  Sicily), 
and  to  try  high  health  resorts  (Davos),  etc.  For  prophylactic  reasons, 
individuals  with  a  predisposition  to  tubercular  disease,  or  scrofulous 
patients,  should  be  built  up  by  a  tonic  treatment  and  kept  from  associ- 
ating with  those  who  actually  have  the  disease. 

Treatment  of  Tuberculosis  with  Koch's  Tuberculin.— The  treatment  of 
tuberculosis  with  Koch's  tuberculin,  a  metabolic  product  of  the  tubercle 
bacilli,  is  of  great  scientific  interest,  and  discloses  a  reformatory  prospect  for 
the  treatment  of  chronic,  and  perhaps  also  of  acute,  infectious  diseases.  It 
is  founded  upon  the  idea  of  killing  the  tubercle  bacilli  or  the  tubercular 
focus  by  the  products  of  their  own  metabolism.  We  know,  in  fact,  that  bac- 
teria, particularly  tubercle  bacilli,  dig  their  own  grave  under  certain  condi- 
tions and  after  the  lapse  of  a  certain  lengtli  of  time.  Koch's  tuberculin  is, 
according  to  the  statements  of  the  discovei*er.  a  glycerine  extract  from  pui-e 
cultures  of  tubercle  bacilli,  a  brownish-red  fluid  which  contains,  in  addition 
to  the  active  principle,  a  toxalbumen,  indifferent  colouring  matters,  salts,  and 
extractives.  In  animals  (guinea  pigs)  Koch  has  obtained  very  satisfactory- 
results  with  tuberculin  ;  he  has  cured  tubercular  guinea-pigs,  and  has  made 
others  unsusceptible  to  inoculation  with  tubercle  bacilli.  In  animals  the 
tubercular  foci  are  cast  off  in  a  state  of  neci'osis  after  the  subcvitaneous  injec- 
tion of  tuberculin. 

The  observations  which  have  been  made  upon  the  use  of  tuberculin  for 
tuberculosis  in  man  have  not  been  as  satisfactory  as  in  guinea-pigs.     After 


422  INFLAMMATION   AND   INJURIES. 

its  subcutaneous  injection  in  tubercular  individuals  there  generally  occurs 
within  about  four  to  six  hours  a  typical  local  and  constitutional  reaction  which 
is  best  illustrated  in  tuberculosis  of  the  skin,  or  lupus.  The  local  histological 
changes  following  the  injection  of  tuberculin  have  been  described  by  many 
authors.  These  changes  consist  in  a  very  active  inflammation  in  the  parts 
surrounding  the  tubercular  focus  ;  the  tubercle  itself  and  the  bacilli  are  not 
directly  attacked.  In  consequence  of  the  inflammation  of  the  parts  sur- 
rounding the  tubercular  focus,  the  latter  may  be  cast  off  under  suitable  con- 
ditions, but  the  typical  necrotic  destruction  of  the  tubercular  focus  observed 
by  Koch  in  animals  following  the  action  of  the  tuberculin  does  not  appear  to 
take  place,  as  a  rule,  in  man.  In  consequence  of  this  inflammation  of  the 
surrounding  parts  the  tubercular  focus  in  lupus,  for  example,  becomes  very 
much  swollen,  a  tubercular  joint  becomes  extremely  painful,  etc.  The  con- 
stitutional effect  of  tuberculin  observed  even  in  healthy  people  after  the  ad- 
ministration of  very  large  doses  consists  in  fever  and  the  other  well-known 
febrile  constitutional  manifestations,  which  may  assume  a  threatening  char- 
acter. I  have  frequently  observed  a  rise  of  temperature  to  41°  C.  (105  8°  F.) 
and  higher,  and  a  pulse  of  180  to  200.  Examination  of  the  blood  reveals  a 
temporary  acute  leucocytosis  in  which  all  forms  of  the  white  blood-corpus- 
cles are  involved.  In  consequence  of  this  characteristic  effect  of  the  tuber- 
culin upon  the  tubercular  focus  the  remedy  has  great  diagnostic  value;  only 
in  exceptional  cases  does  the  typical  reaction  fail,  as  it  did,  for  instance,  in  a 
case  coming  under  my  observation  and  subsequently  operated  upon,  in  which 
there  was  tuberculosis  of  the  testicle  and  kidney.  The  typical  reaction  is 
occasionally  observed  even  in  people  seemingly  healthy,  and  then  usually 
means  a  latent  tuberculosis.  In  the  case  of  an  apparently  healthy  medical 
student,  I  observed,  after  subcutaneous  injection  of  the  tuberculin,  a  marked 
swelling  of  the  cervical  lymphatic  glands  and  high  fever  ;  the  cause  of  this 
proved  to  be  an  anatomical  tubercle  on  the  chin,  microscopical  examination 
of  which  after  extirpation  revealed  typical  tubercles.  If  a  healthy  person  Je)" 
reacts  to  tuberculin,  a  latent  tuberculosis,  as  said  before,  may  be  present.  '  ^ 

The  therapeutic  results  obtained  with  tuberculin  are  not  as  satisfactory 
in  man  as  in  animals.  There  are  numerous  reports  upon  the  tuberculin 
treatment,  particularly  of  lupus,  but  permanent  cures  have  only  been  ob- 
tained in  very  rare  instances,  and  not  infrequently"  the  tubercular  process  has 
been  made  worse.  Unfortunatelj'  the  remedy  has  not  always  been  used  in 
properly  selected  cases.  At  present  tuberculin  is  scarcely  employed  at  all. 
Though  Robert  Koch  may  not  have  discovered  the  means  of  curing  tubercu- 
losis in  man,  he  is  perhaps  upon  the  right  road  to  find  a  valuable  means  of 
assistance  in  the  treatment  of  tuberculosis,  particularly  in  its  early  stages. 
The  conditions  for  rendering  it  possible  to  cure  surgical  tuberculosis  are 
most  favourable  in  those  cases  where  the  tuberculin  treatment  can  be  proper- 
ly combined  with  the  operative. 

As  to  the  technique  of  the  method,  I  may  say  that  I  employ  small  doses 
and  not  too  frequent  injections,  preferably  under  the  skin  of  the  back.  I 
begin  without  exception  with  one  milligramme  of  tuberculin  for  adults  and 
half  a  milligramme  for  children,  once  or  twice  a  week,  gradually  increasing 
the  dose  to  O'Ol  to  O'lO  gramme.  I  do  not  use  large  doses — for  example,  0*20  to 
0"50  gramme  or  more.     By  the  use  of  small  doses  once  or  twice  a  week  the 


§83.]  TUBKRCUfiOSrS.  423 

markod  loss  of  woi^'lit,  occurrijig-  so  easily,  is  j)revoTite(l,  as  are  also  the  harm- 
ful constitutional  symptoms.  I  have  used  the  tuherculin  in  a  great  num- 
ber of  cases  of  surgical  tuberculosis,  and  in  some  of  them  1  have  observed 
remarkable  improvement,  but  no  cures  either  in  lupus  or  in  any  other  tuber- 
culosis of  soft  parts,  bones,  or  joints.  I  am  sorry  to  say  that  the  improve- 
ments were  only  temporary  in  their  nature,  and  many  cases  were  even  made 
woi'se. 

The  question  whether  tuberculin  may  occasionally  favour  the  origin  of  a 
general  miliary  tuberculosis — that  is,  whether  tuberculosis  may  be  made 
general  throughout  the  body  by  using  the  remedy — cannot  be  answered  with 
certainty,  but  the  possibility  of  this  must  be  admitted  (Virchow). 

Klebs's  Tuberculocidin.— Klebs  has  separated  from  the  healing  substances 
in  Koch's  tuberculin  tliose  which  are  noxious  (which  produce  the  necrosis) 
by  precipitation  with  platinum  chloride  and  phospliortungstic  acid  and  by 
the  addition  of  alcohol  to  the  residue.  The  medicinal  substance  thus  ob- 
tained, tuberculocidin,  which  belongs  to  the  peptone  group,  has  been  found 
by  Klebs  to  be  of  therapeutic  value. 

Cantharidate  of  Potassium. — Liebreich  recommended  the  subcutaneous 
injection  of  the  cantharidate  of  potassium  (up  to  sixty  grammes)  ;  its  action 
is  the  same  as  that  of  tuberculin.  B.  Frankel,  Heymann  and  Landgraf 
likewise  obtained  satisfactory  results.  Martin  and  Grancher  claim  to  have 
made  rabbits  immune  from  infection  with  tubercle  bacilli  of  the  highest 
grade  of  virulence  by  first  inoculating  them  with  tubercle  bacilli  of  weaker 
but  gradually  increasing  virulence. 

In  this  connection  a  brief  description  should  be  given  of  the  nature 
and  treatment  of  scrofula. 

Scrofula.— By  scrofula  (from  scrofa,  hog)  is  understood  a  constitutional 
anomaly  without  anatomical  changes  that  are  capable  of  being  positively 
demonstrated.  It  is  characterised  by  a  striking  weakness  of  the  tissues,  or 
rather  of  the  cells,  rendering  them  incapable  of  withstanding  injurious  influ- 
ences from  without.  Consequently  we  observe  that  scrofulous  individuals, 
as  a  result  of  the  slightest  external  violence,  suffer  from  inflammations  of 
every  description,  which  may  involve  the  skin,  mucous  membranes,  or  lym- 
phatic glands.  Scrofulous  people,  as  we  have  remarked  before,  possess  a  pro- 
nounced predisposition  to  tuberculosis — that  is,  the  scrofulous  constitutional 
anomaly,  with  its  local  acute  and  chronic  foci  of  inflammation,  is  an  excellent 
soil  for  the  tubercle  bacillus.  The  relationship  between  scrofixla  and  tuber- 
culosis has  been  very  frequently  discussed,  and  since  the  discovery  of  the 
tubercle  bacillus  the  connection  between  them  has  become  better  understood. 
We  now  assume  that  scrofula  has  nothing  to  do  with  true  tuberculosis;  it  is 
rather  a  constitutional  anomaly  by  which  infection  with  the  bacillus  tuber- 
culosvis  is  favoured. 

If  we  have  to  deal  with  a  cheesy  or  suppurative  lymphadenitis,  which  is 
so  often  observed  in  scrofula,  the  decision  as  to  whether  we  have  to  deal  with 
tuberculosis  or  not  is  made  solely  upon  the  demonstration  of  tubercle  bacilli. 
The  same  thing  holds  true  of  the  so-called  cold,  scrofulous  abscess  in  the  soft 
parts,  and  the  chronic  inflammations  of  bones  and  soft  parts.     I  am  of  the 


424r  INFLAMMATION  AND   INJURIES. 

opinion  that  a  pseudo-tuberculosis  occurs  in  scrofulous  individuals  which  is 
analogous  to  that  observed  in  animals,  which  was  described  by  Eberth,  Ma- 
lassez,  and  Vignal  (page  412);  it  runs  a  course  similar  to  true  tuberculosis, 
thouf'-h  caused  by  other  micro-organisms  (cocci,  bacilli  i,  and  not  by  the  Vjacil- 
lus  tuberculosus  Kochii. 

The  scrofulous  constitutional  anomaly  is  either  congenital  or  acquired, 
as  a  result  of  unfavourable  external  hygienic  conditions,  a  lack  of  proper 
nourishment,  living  in  bad  surroundings,  etc.  The  most  important  marks 
of  scrofula  consist,  in  the  first  ijlace,  of  a  sei'ies  of  manifestations  which  are 
usually  grouped  together  under  the  name  of  habitus  scrofulosus.  For  con- 
venience we  distinguish  two  forms  of  scrofula:  the  irritable  and  the  torpid 
form.  Scrofulous  individuals  have  in  general  a  thin,  delicate,  transparent 
skin ;  they  are  more  apt  to  be  blond  than  dark,  and  are  of  a  very  excitable 
temperament  (irritable  form).  In  the  tori)id  form  of  scrofula  the  skin  is 
more  puffed,  the  subcutaneous  fat  remarkably  well  develoi)ed,  and  the  ab- 
domen protruding.  But  all  these  manifestations  are  observed  without  scrof- 
ula, and  the  latter  first  becomes  evident  to  the  eye  when  local  inflamma- 
tory manifestations  make  their  appearance,  particularly  inflammations  of 
the  skin,  mucous  membranes,  and  glands.  Of  these,  the  most  constant  are  : 
Eczemas  of  every  description  which  are  so  common;  the  catarrh  of  the  throat, 
bronchi,  stomach,  and  intestines;  the  pronounced  conjunctivitis,  blepharo- 
adenitis.  and  keratitis.  The  lymph  glands  are  usually  swollen  and  enlarged, 
■with  or  without  simultaneous  cheesy  degeneration.  This  is  pai'ticularly  the 
case  with  the  lymph  glands  of  the  neck  and  submaxillarj'  region,  where  great 
ma.sses  of  enlarged  lymph  glands  may  exist.  In  this  way  the  neck  becomas 
very  plump,  and  merges  gradually  into  the  head  and  trunk,  as  in  pigs.  The 
old-fashioned  term  of  scrofula  was  derived  from  this  comparison.  In  this 
caseous  lymphadenitis  the  transitions  to  true  tuberculosis  are  very  common. 

Treatment  of  Scrofula. — The  treatment  of  scrofula  must  be  directed  first 
and  chiefly  towards  overcoming  the  existing  constitutional  anomaly,  particu- 
larly by  the  enforcement  of  proper  hygienic  rules — that  is.  by  taking  care  to 
svxpply  good  nourishment,  air,  and  light;  by  proper  exercise  in  fresh  air;  by 
muscular  exertion  (gymnastics,  swimming),  etc.  A  residence  at  the  seaside 
is  particularly  to  be  recommended  in  scrofula.  This  does  not  have  a  specific 
effect  ;  it  is  only  an  adjuvant  in  the  cure,  exciting  the  appetite  of  the  patient 
and  thus  improving  his  nutrition.  The  diligent  use  of  salt  baths  (up  to  three 
per  cent.)  has  a  good  reputation  in  the  treatment  of  scrofula  ;  they  should  be 
employed  daily,  or,  in  the  case  of  weak  individuals,  two  to  three  times  a  week 
and  for  ten  to  thirty  minutes.  Kreuznach.  Xauheim.  Oeynhausen,  Reicben- 
hall  and'Heilbronu  have  the  best  reputation  amongst  the  bathing  resorts. 
They  are  particularly  recommended  on  account  of  the  iodine  and  bromine 
contained  in  the  waters.  The  water  is  used  to  drink  as  well  as  to  bathe  in. 
The  administration  of  cod-liver  oil,  fifteen  to  twenty  to  thirty  grammes  a 
day,  particularly  in  winter,  is  likewise  recommended.  Cod-liver  oil  is  an 
easily  digestible  fat  of  dietetic  importance.  Furthermore,  scrofulous  subjects 
should  be  cautiously  toughened  by  degrees,  to  render  them  more  capable  of 
withstanding  the  frequent  catarrhs  of  the  mucous  membranes.  Every 
scrofulous  local  disease  should  receive  proper  treatment.  In  the  matter  of 
prophylaxis,  too  much  emphasis  cannot  be  laid  upon  the  importance  of  pro- 


§84.] 


SYPHILIS. 


425 


'#. 


*:^-->r^^^ 


Fig.  293.  —  Wandering  cells  with 
syphilis  bacilli,  x  1,050  (Lust- 
garten). 


O 


©^( 


tecting  scrofulous  rhildron  from  contagion  with  tuberculosis,  and  from  inter- 
course with  those  who  have  the  latter  disease. 

§  84.  Syphilis  {Lues). — \^y  syphilis  we  understand  a  chronic  infec- 
tious disease  ^vhicll,  according  to  recent  investigations,  is  most  prob- 
ably caused,  like  tuberculosis,  by  a  characteristic  fungus.  Klebs  and 
I3ii"ch-Ilirschfeld  were  the  first  to  discover  micro-organisms  in  syphilis, 
and  to  look  upon  them  as  the  cause  of  the  disease.  By  transference  of 
the  bacilli  to  apes,  Klebs  brought  about 
inlhuunuitions  some  of  which  ran  a  course 
similar  to  the  inflammation  in  sy])hilis, 
others  to  that  in  tuberculosis.  Lustgarten, 
under  AVeigert's  guidance,  by  using  a  spe- 
cial method,  succeeded  in  demonstrating 
in  tissues  which  had  undergone  syphilitic 
changes,  and  in  the  secretion  from  syphi- 
litic ulcers,  a  particular  species  of  bacillus 
(Figs.  293,  294-)  which  is  morphologically 
similar  to  the  tubercle  bacillus,  but  differs 
from  it  in  shape,  more  frequently  occur- 
ring in  a  slightl}^  curved  form,  with  knob- 
shaped  enlargements  at  its  ends.  It  also 
diifers  in  its  micro-chemical  behaviour. 
While  the  tubercle  and  lepra  bacilli,  which 
are  also  brought  to  view  by  Lustgarten's 
method,  are  not  decolourised  by  hydro- 
chloric or  nitric  acids  (or  only  after  being 
subjected  to  them  for  a  long  time),  the 
syphilis  bacilli  rapidly  part  with  their  stain 
under  the  influence  of  these  acids.  The  syphilis  bacteria,  as  yet,  are 
not  distinguished  by  any  other  absolutely  characteristic  staining  reaction. 
The  syphilis  bacilli  are  stained  by  Lustgarten  as  follows :  The  thinnest 
possible  sections  are  treated  with  aniline-gentian  violet  for  twelve  to 
twenty-four  hours,  at  the  ordinary  room  temperature,  then  for  two 
hours  longer  at  a  temperature  of  40°  C.  in  the  incubator,  washed  in 
absolute  alcohol  for  several  minutes,  then  for  about  ten  seconds  in  a 
one-and-a-half-per-cent.  solution  of  permanganate  of  potassium  and  for 
one  to  two  seconds  in  an  aqueous  solution  of  sulphuric  acid,  and  then 
washed  in  distilled  water.  The  latter  three  steps  should  be  repeated 
many  times  until  the  section  appears  completely  colourless,  then  it  is 
treated  with  alcohol,  oil  of  cloves,  and  xylol-Canada  balsam.  Cover- 
glass  preparations  are  treated  in  a  similar  way,  except  that,  after  stain- 
ing in  gentian  violet,  distilled  water  is  used  instead  of  absolute  alcohol, 


ao 


Fig.  204. — Ury  preparation  oi  pus 
taken  from  a  syphilitic  sclerosis 
with  syphilis  bacilli,  x  1,050 
(Lustgarten). 


426  INFLAMMATION   AND   INJURIES. 

and  the  separate  steps  in  the  process  follow  one  another  more  rapidly. 
Lustgarten  never  found  the  bacilli  free  in  the  tissues,  but  alwaj^s  either 
singly  or  in  groups  of  from  two  to  eight  individuals  in  large  oval  or 
polygonal  cells,  and  chiefly  in  the  wandering  cells  (Fig.  293).  The 
bacilli  are  usually  to  be  found  only  in  small  numbers,  and  they  are  most 
frequently  capable  of  demonstration  in  the  cover-glass  preparations 
(Fig.  294),  rarely  in  the  sections.  Doutrelepont,  Schiitz  and  others  have 
likewise  proved  the  presence  of  Lustgarten's  bacilli  in  syphilitic  tissues 
and  secretions,  but  they  have  not  found  them  in  every  case.  De  Gia- 
comi  stains  the  preparations  in  Ehrlich's  aniline-water-f  uchsin  solution, 
and  then  treats  them  with  a  chloride-of-iron  solution. 

The  significance  of  Lustj^arten's  bacilli  has  been  rendered  somewhat 
doubtful  by  Alvarez,  Tavel,  Matterstock,  and  others.  These  authors 
have  found  in  the  praspntial  smegma,  and  in  the  secretion  between  the 
labia  majora  and  minora  and  about  the  anus,  bacilli  having  the  same 
appearance  and  the  same  staining  reaction  as  Lustgarten's  syphilis 
bacilli.  This  fact  has  been  confirmed  in  every  respect  by  Doutrele- 
pont, Markus,  and  many  others.  But  the  circumstance  that  the  syph- 
ilis bacilli  are  present  in  syphilitic  tissue  where  there  can  be  no  smegma 
bacilli  has  the  greatest  significance  as  regards  their  specific  importance. 
At  all  events,  the  etiological  importance  of  Lustgarten's  bacilli  must  be 
tested  by  further  investigation,  and  the  question  must  remain  unsettled 
as  long  as  it  continues  to  be  impossible  to  artificially  cultivate  the  syph- 
ilis bacteria  and  to  inoculate  them  successfully  upon  susceptible  ani- 
mals. Doutrelepont  believes  that  Lustgarten's  bacilli  really  bear  some 
sort  of  relationship  to  syphilis,  while  other  authorities  hold  the  con- 
trary view.  Weigert  also  believes  in  the  specific  significance  of  Lust- 
garten's syphilis  bacilli.  Biiunder  is  of  the  opinion,  as  are  by  far  the 
greater  number  of  physicians,  that  syphilis  is  caused  by  specific  micro- 
organisms, but  that  this  species  of  bacteria  has  not  yet  been  demon- 
strated with  certainty. 

Transmission  of  Syphilis  to  Animals.— Disse  and  Taguchi  claim  to  have 
found  in  the  blood  of  syphilitic  subjects,  partly  by  microscopical  examina- 
tion and  partly  by  Koch's  culture  methods,  spore-forming  bacilli,  by  inocula- 
tion of  which  upon  animals  they  have  excited  in  the  latter  syphilitic  diseases. 
This  statement  must  be  regarded  with  suspicion,  as  should  be  the  analogous 
reports  of  Martineau  and  Hamonic  upon  positive  transmission  experiments, 
since  it  has  hitherto  been  the  common  experience  to  find  that  the  syphi- 
litic poison  cannot  be  successfully  inoculated  upon  animals.  Furthermore, 
the  experiments  of  Klebs  relating  to  inoculation  upon  apes,  as  stated  before, 
yielded  doubtful  results. 

Origin  of  Syphilis. — Syphilis  originates  by  the  poison  being  directly 
transferred  from  one  individual  to  another,  particularly  during  coitus. 


g84.]  SYPHILIS.  427 

The  transference  of  the  poison  by  infected  objects  is  in  general  rare. 
The  broad  condylomata  (moist  papules,  see  p.  430)  are  the  most  fre- 
quent source  of  the  contagion.  It  has  not  yet  been  positively  settled 
whether  the  contents  of  the  gummata,  or  in  general  of  the  local  forma- 
tions of  the  tertiary  period  of  syphilis,  possess  the  power  of  producing 
infection.  The  transference  of  syphilis  is  only  possible  when  the 
poison  is  inoculated  in  an  injured  spot,  in  some  interruption  of  conti- 
nuity, for  instance,  of  the  most  superficial  layer  of  the  skin,  which 
may  often  be  very  insignificant.  The  syphilis  poison  reproduces  itself 
apparently  only  in  the  human  organism,  since  indisputable  inoculations  - 
in  animals,  as  stated  above,  have  not  hitherto  been  observed. 

The  Different  Ways  in  which  Syphilis  may  Originate.— The  published 
statistics  upon  the  frequeucy  of  the  pi-opagatiou  of  syphilis  in  ways  other 
than  by  coitus  vary  greatly.  But,  in  general,  an  extragenital  origin  of 
syphilis  is  more  common  in  women  than  in  men.  This  appeared  formerly 
to  be  of  more  frequent  occurrence  than  now,  pi'obably  because  the  danger  of 
contagion  was  not  so  well  understood.  According  to  Jullien  and  Fournier, 
an  extragenital  origin  of  syphilis  in  men  occm^s  in  from  five  to  sLx  per  cent. 
of  the  cases;  in  women,  on  the  other  hand,  in  from  twenty-five  to  twenty-  ^  <r"-  "a 
sis  per  cent.  Mracek  (Siegmund's  clinic)  gives  an  extragenital  infection  of 
one  per  cent,  for  men  and  fourteen  per  cent,  for  women. 

The  different  portions  of  the  body  which  are  tlie  seat  of  the  primary  extra- 
genital infection  of  syj)hilis  are,  in  the  order  of  frequency,  as  follows:  Lips, 
anus,  finger,  tongue,  breast,  abdomen,  leg,  palate.  Finger  infection  is  par- 
ticularly common  in  physicians  and  midwives.  Syphilis  can  also  be  trans- 
ferred by  the  primary  lesion  on  the  hands  of  physicians  and  mid\^-ives  to 
their  patients  (Xeisser).  It  is  not  infrequently  transferred  by  infected  instru- 
ments—for example,  in  dental  operations,  in  shaving,  etc.  A  careful  sani- 
tary police  control  in  the  matter  of  the  cleanliness  of  shaving  instruments 
would  certainly  be  desu-able  in  every  respect.  It  is  undoubtedly  possible 
that  syphilis  may  be  transmitted  by  vaccination.  Occasionally  an  entire 
family  may  become  infected  by  a  syphilitic  nurse. 

Inheritance  of  Syphilis. — The  question  as  to  whether  syphilis  can  be  in- 
herited is  of  great  practical  import.  As  a  matter  of  fact,  it  has  been  proved 
that  it  can  be.  Kassowitz  has  recently  investigated  this  question  with  great 
care.  The  inheritance  of  syphilis  is  possible  in  two  different  ways: 'by  the 
poison  attaching  itself  to  the  spermatozoon  or  the  ovum,  or  by  the  healthy 
foetus  becoming  infected  from  the  blood  of  the  mother  (intra-uterine  infec- 
tion). It  has  been  proved  that  syphilis  may  be  inherited  in  the  first  of  these 
t_wo  ways,  and  it  appears  to  proceed  from  the  father  more  frequently  than 
from  the  mother.  The  transmission  of  syphibs  by  the  father  alone — that  is, 
by  the  spermatozoa — has  been  proved  by  the  fact  observed  by  many  authors, 
such  as  Hebra.  Gerhardt,  Weil,  etc.,  that  a  non-syphilitic  mother  can  give 
birth  to  a  syphilitic  child.  The  intra-uterine  infection,  on  the  contrary,  has 
not  hitherto  been  demonstrated;  but  it  is  theoretically  conceivable  and  possi- 
ble for  a  woman,  who  becomes  syphilitic  during  her  pregnancy,  to  infect  her 


428  IXFLAMMATIOX   AXD   INJURIES. 

child  by  means  of  the  blood-channels.  But  we  should  not  omit  to  say  that 
Bai'ensprung  and  Kassowitz,  particularly,  have  vigorously  contested  the  pos- 
sibility of  this  intrauterine  infection,  on  the  ground  that  it  would  be  impos- 
sible for  the  syphilis  poison  to  pass  through  the  placenta.  As  a  matter  of  fact, 
it  frequently  happens  that  women  with  recent  syphilis  give  birth  to  children 
who  are  healthy  and  remain  so. 

Still  another  question  is  of  great  practical  importance.  Can  a  syphilitic 
foetus,  originating,  for  instance,  from  syphilitic  spermatozoa,  infect  its  healthy 
mother  ?  Such  an  occurrence  is  contested,  like  the  above-mentioned  inti*a- 
uterine  infection  of  the  foetus  from  the  mother,  but  as  a  matter  of  fact  it  has 
not  as  yet  been  proved. 

The  recent  investigations  of  Birch-Hii-schfeld  in  regard  to  the  question  of 
foetal  infection  are  exceedingly  interesting  (see  also  p.  -416).  As  he  has  main- 
tained, the  placenta,  under  normal  conditions,  is  impervious  for  finely  divided 
foreign  bodies  and  micro-organisms,  but  the  filter  may  become  pervious  by 
pathological  processes,  or  bj'  the  lodgement  in  it  of  micro-organisms,  so  that 
then  bacteria  in  particular,  such  as  tubercle  and  anthrax  bacilli,  pass  over 
from  the  maternal  to  the  foetal  circulation,  or  rather  grow  tki-ough  the 
tissues. 

Kassowitz  and  others  found  streptococci  in  children  with  hereditai'y  syph- 
ilis, especially  in  the  mucous  patches.  They  are  to  be  considered  in  the 
main  as  a  result  of  a  secondary  infection  from  a  wound  of  the  skin  or  mu- 
cous membrane.  In  fresh  syphilis  of  the  parents  the  foetus  usually  dies 
before  the  end  of  pregnancy.  In  attenuated  late  s\-philis  of  the  parents  the 
child  is  more  apt  to  be  carried  to  full  term  and  then  born  with  manifest 
signs  of  syphilis,  or  the  syphilis  appeal's  soon  after  bu*tb.  Occasionally  heredi- 
tary sy})hilis  makes  its  first  appearance  very  late,  as  Fournier  in  particular 
has  recently  shown.  Such  cases  of  syphilis  hereditaria  tarda  are  not  infre- 
quently confused  with  scrofula  or  tuberculosis.  "When  the  correct  diagnosis 
is  made  in  such  cases,  remai'kable  success  can  be  obtained  by  the  adoption  of 
antisyphilitic  treatment.  In  general  the  phenomena  of  congenital  syphilis 
are  the  same  as  in  the  acquired.  There  are  observed  the  same  tertiary  mani- 
festations, with  serious  pathological  changes  in  the  skin,  the  viscera,  and  the 
bones  (Pan'ot,  Lannelongue).  It  is  important  to  note  that  deafness  or  diffi- 
culty in  hearing  occur  rather  frequently  in  hereditary  syphilis. 

When  can  a  Syphilitic  Individual  Marry?— The  question  as  to  when  a 
syphilitic  individual  can  be  given  permission  to  marry  is  difficult  to  answer. 
In  general,  this  should  be  allowed  only  vylien  a  proper  treatment  has  been 
carried  out  continuously,  and  no  recurrences  have  taken  place  for  from  three 
to  fom-  yeai's  after  the  infection. 

Symptoms  and  Course  of  Syphilis. — If  we  grant  that  syphilis  is  an  in- 
fectious bacterial  disease,  it?  manifestations  will  be  caused  partly  by  the 
inicro-organisms  themselves  and  partly  by  the  toxines  which  they  form. 
Syphilis  usually  begins  with  the  appearance  at  the  point  of  infection 
of  the  so-called  syphilitic  initial  sclerosis,  or  Hunter's  induration,  or 
the^ard  chancre.  This  specific  formation  is  usually  first  capable  of 
demonstration  two  to  four  weeks  after  infection,  thousch  sometimes 


55  84.]  SYPHILIS.  429 

sooner.  The  primary  sypliilitic  initial  sclerosis  is  usually  a  hard  (indu- 
rated), painless  (indolent)  nodule,  which  gradually  increases  in  circuin- 
ference  and  then  most  commonly  changes  into  an  ulcer.  In  this  way 
ulcers  are  formed  with  a  hard,  parchment-like  base,  or  the  order  is 
reversed,  and  a  vesicle  develops  tirst,  which  ulcerates  and  then  indu- 
rates. Often  enough  the  syphilitic  initial  infection  is  so  small  that  it 
is  easily  overlooked,  particularly  in  women,  and  the  secondary  mani- 
festations occurring  after  a  certain  length  of  time  are  the  first  indica- 
tion that  syphiHtic  infection  has  taken  place.  Only  in  rare  instances 
is  the  syphilitic  primary  infection  complicated  by  phagedenic  changes 
— that  is,  by  spreading  gangrene. 

The  microscopical  examination  of  the  syphilitic  initial  sclerosis,  or 
of  the  primary  syphilitic  scleroma,  shows  that  W'e  have  to  deal  essen- 
tially with  a  collection  of  round  cells,  epithelioid  cells,  and  occasionally 
giant  cells  (Fig.  295).  These  cells  break  down  after  a  certain  length 
qf^time,  giving  rise  to  an  ulcer  ;  finally,  the  disintegrated  cells  are  ab- 
sorbed, and  cicatrisation  occurs. 

Six  to  eight  weeks  after  the  infection,  or  later,  the  constitutional 
manifestations  of  syphilis  make  their  appearance,  and  are  due  to  the 
fact  that  the  poison  has  been  taken  into  the  circulation  from  the  pri- 
mary focus  of  infection  and  carried  through  the  entire  body.  The 
twelfth  day  is  the  earliest  period  at  b 

which  the  outbreak    of  the   consti-  ^^^      i'*'*      -^?V^«> 

tutional  manifestations  has  hjtherto  '  '"       '  0 

been    observed.       Occasionallv    the  3  - 

constitutional  symptoms  occur  very  is  '| 

late — for  instance,  in  eases  seen  by     ^  \ 

Giinz   and    liinecker,  one  hundred  .,  f) 

and   thirty  and    one    hundred    and  :  '^: 

fifty-nine  days  respectively  after  in-  ,\ 

fection.     Of  the  symptoms  of  syph-  „^.   ..        ,      ,    .  ^.  ivil 

ilitic    constitutional    infection,    the  "^        -  ~    a^''^^    . 

'  first  to  occur  is  an  enlargement  of    F"^-  so.^.-^^ption  throu.rh  a  hard  chancre  -. 

o  a.  round  celled  ninltration  ;  b.  large  ino- 

the   lymph    glands   in    different  parts  nonudear  cells;  and  o,polynuclear  giant 

•^       '     ^  .  cells.     na?niato.\ylin  staining,  x  300. 

of  the  body  ;  for  example,  in  the 

inguinal  region,  at  the  elbow,  in  the  neck,  etc.  They  can  readily  be 
made  out  by  palpation.  '  Then  the  skin  and  mucous  membranes  be- 
come diseased.  We  observe  spotted  (macular)  or  nodular  (papular), 
exfoliating  (desquamating)  or  large  tuberous  eruptions  of  the  skin ; 
also  cutaneous  ulcers,  ulcers  on  the  palate,  the  lips,  tongue,  anus,  etc. 
Occasionally  the  spots  upon  the  skin,  particularly  in  women,  have  a 
whitish   character   (leucoderma   syphilitica).     In    conjunction   with    a 

28 


430  INFLAMMATION   AND   INJURIES. 

severe  syphilitic  exanthema  there  is  sometimes  observed  a  circum- 
scribed atrophy,  or  thinning  of  the  skin,  in  the  form  of  bhiish-coloured 
areas,  in  which  the  cutis  forms  very  small  folds.  Following  the  above- 
mentioned  manifestations  in  the  skin  and  mucous  membranes,  there 

s  .  .  .       . 

occur  later  syphilitic  diseases  of  the  internal  organs,  ]>articularly  the 

testicle,  liver,  brain,  bones,  joints,  muscles,  and  peripheral  nerves, 
j^  Amongst  the  bones  most  commonly  affected  are  those  of  the  skull,  the 
tibia,  and  the  sternum.  In  the  skull  and  nose,  as  we  shall  see  in  the 
special  portion  of  this  text-book,  there  occur  very  characteristic  losses 
of  substance.  The  syphilitic  diseases  of  the  central  nervous  system 
and  of  the  peripheral  nerves  are  of  great  practical  importance.  De- 
generation of  the  posterior  columns  of  the  cord  (tabes)  is  observed  in 
syphilitic  subjects  particularly  (Erb).  The  syphilitic  poison  may  be 
deposited  in  all  the  organs  and  in  every  tissue  and  excite  chronic  in- 
flammatory processes  of  various  kinds,  especially  in  the  walls  of  the 
— >  vessels,  in  the  form  of  a  syphilitic  endarteritis,  in  which  there  is  a 
thickening  of  the  wall,  particularly  of  the  intima,  and  a  narrowing,  or 
even  closure,  of  the  lumen,  as  has  been  described  by  Heubner  and 
others.  In  other  parts  there  are  produced  by  the  syphilitic  inflamma- 
tion either  circumscribed  growths  or  diffuse  inflammatory  infiltrations, 
with  a  tendency  towards  cicatricial  formation.  Amongst  the  circum- 
scribed specific  formations  of  syphilis  should  be  mentioned,  first  of  all, 
the  gumma  (Virchow),  which  is  also  called  syphiloma  (E.  Wagner), 
/-  and  the  broad  condyloma  (condyloma  latum).  The  syphilomata,  gum- 
mata,  or  gumma  tumours,  so  called  on  account  of  their  characteristic 
elastic  property,  are  observed  especially  in  the  testicle,  liver,  spleen, 
meninges,  periosteum,  the  marrow  of  the  bones,  and  occasionally  also 
in  the  blood-vessels  (Virchow,  Baumgarten,  and  Langenbeck).  They 
are  either  jelly-like  formations,  with  few  cells,  or  nodes  made  up 
largely  of  cells,  and  more  or  less  like  granulation  tissue,  with  the  single 
difference  that  the  new  formation  of  vessels  is  very  limited.  By  the 
breaking  down  of  the  gummatous  nodes  extensive  ulcerations  occasion- 
ally result,  particularly  in  the  skin.  The  majority  of  tumours  which 
make  their  appearance  in  the  muscles  are  of  syphilitic  origin.  The 
muscular  syphiloma  has  a  predilection  far  the  sterno-cleido-mastoid, 
which,  according  to  F.  Karewski,  is  affected  in  one  third  of  all  the 
cases.'  In  oth^r  cases  the  mj^ositis  syphilitica  is  diffuse.  Many  of  the 
so  called  "  rheumatic  muscular  thickenings  "  can  be  referred  to  syphilitic 
processes  (Braman).  The  broad  condyloma  is  found  particularly  about 
the  vulva  and  the  anus.  It  presents  itself  in  the  form  of  a  papillary, 
moist  induration  of  the  skin  or  mucous  membranes,  caused  by  serous 
transudation  and  cellular  infiltration  of  the  corium  or  mucous  membrane. 


^  H4.]  SYPHILIS.  431 

The  sy])liilitic  diseases  of  joints  (sec  also  Diseases  of  Joints)  wliicli 
occur  in  the  later  stages  of  syphilis  are  particularly  interesting.  Ana- 
tomically they  sometimes  take  the  form  of  circumscribed  ulcerations 
or  carious  processes,  iibrillations  of  the  cartilage  with  the  formation  of 
villous  excrescences,  and  sometimes  a  proliferation  of  connective  tis- 
sue or  cicatricial  tissue  in  the  form  of  bands,  or  more  diffuse  growths. 
The  ulcerative  or  carious  processes  are  essentially  due  to  the  gumma- 
tous infiltrations,  and  the  cicatricial  tissue  is  the  final  result  of  inflam- 
mations of  this  sort. 

Extensive  haemorrhages  are  observed,  particularly  in  hereditary 
py{)hilis,  as  the  result  of  local  diseases  of  the  vessels  and  the  parenchyma 
(Mracek,  syphilis  luvmorrhagica  neonatorum). 

All  these  diverse  manifestations  of  syphilis  which  have  been  so 
briefly  outlined  can  be  divided  into  three  stages. 

Z  The  first  stage  includes  the  incubation  period  of  syphilis — that  is, 
the  formation  of  the  local  syphilitic  sclerosis  or  the  llunterian  indura- 
tion at  the  point  of  infection. 

The  second  stage  begins,  some  six  to  eight  weeks  after  the  infec- 
tion, with  the  occurrence  of  the  first  constitutional  manifestations 
(swelling  of  the  lymph  glands,  a  macular,  papular,  or  scaly  eruption  on 
the  skin  and  mucous  membranes),  which  are  accompanied  by  more  or 
less  fever.  The  other  cutaneous  affections  for  the  most  part  appear 
two  to  three — less  often  four  to  six — months  after  the  infection.  Ac- 
cording to  Siegmund,  syphilis  can  be  stamped  out  at  this  stage  by 
proper  treatment  in  about  forty  per  cent,  of  all  cases. 

The  third  stage  is  characterised  by  the  occurrence  in  the  different 
organs  of  gummatous  forms  of  inflammation. 

Still  a  fourth  stage  can  be  added  if  so  desired,  including  the  syj^hi- 
litic  atrophy  and  the  syphilitic  marasmus.  In  general,  the  severe 
form  of  syphilis  passing  through  all  the  different  stages  occurs  when 
the  disease  does  not  receive  proper  care  and  suitable  treatment.  Not 
infrequently  cases  are  observed  which  run  a  decidedly  malignant 
course,  in  which  at  a  relatively  early  period  the  internal  organs  become 
diseased  and  severe  pustular  cutaneous  affections  make  their  appear- 
ance (syphilis  maligna). 

The  Changes  in  the  Blood  in  Syphilis,  according:  to  Bieganski  and  others, 
consist  iu  a  marked  leucqcytosis  which  is  due  essentially  to  an  increase  in 
the  number  of  the  lymphocytes.  The  number  of  the  red  blood-corpuscles  is 
not  altered,  but  the  percentage  of  hsemoglobin  is  diminished.  Under  the 
mercurial  treatment  of  syphilis  the  amount  of  haemoglobin  in  the  blood  in- 
creases again,  and  the  leucocytosis  becomes  diminished. 

Syphilitic  Albuminuria. — The  syphilitic  albuminuria  is  occasionally  ob- 


432  INFLAMMATION   AND   INJURIES. 

served  at  the  beginning  of  the  second  stage,  and  is  usually  completely  and 
permanently  cured  by  antisyphilitic  treatment.  A  second  form  of  syphilitic 
albuminuria,  occurring  in  the  later  stages  of  syphilis,  is  more  unfavourable  ; 
it  generally  marks  the  beginning  of  a  chrenic  nephritis  (Horteloup). 

Syphilitic  Dental  Deformities.— Hutchinson,  in  particular,  has  directed 
attention  to  the  syphilitic  deformities  of  the  teeth  in  congenital  syjphilis. 

Syphilitic  Pseudo-paralyses. — Syphilitic  pseudo-paralyses  are  observed, 
according  to  Parrot  and  others,  for  the  most  part  in  children  two  to  three 
months  old.  Usually  the  children  are  suddenly  unable  to  move  the  affect- 
ed extremity,  most  frequently  the  upper  ;  the  extremity  is  painful,  and  gen- 
erally in  the  region  of  an  epiphysis — the  lower  epiphysis  of  the  humerus,  for 
example— a  diflFuse  swelling  and  slight  crepitation  can  be  made  out.  The 
sensibility  and  the  electrical  excitability  of  the  muscles  are  intact.  The  fin- 
gers can  be  moved  a  little.  Genei'ally,  after  a  certain  length  of  time,  often  a 
few  days,  the  other  upper  extremity  becomes  diseased.  There  may  be  no 
other  indications  of  syphilis,  but  usually  traces  of  past  syphilis  are  present 
in  the  parents.  Complete  recovery  ordinarily  ensues  in  from  two  to  three 
months  under  antisyphilitic  treatment  with  small  doses  of  mercury. 

Syphilis  and  Carcinoma.— Occasionally  syphilis  is  observed  complicated 
by  carcinoma;  i.  e.,  syphilitic  tissue  productions  become  the  seat  of  a  carci- 
noma, and  then  present  important  difficulties  in  diagnosis  which  are  best 
solved  by  careful  microscopical  examination  and  antisyphilitic  treatment. 

The  combination  of  syphilis  with  tuberculosis  is  discussed  on  page  412. 

The  course  of  syphilis  is,  in  general,  very  clironie.  It  often  hap- 
pens tliat  the  syphilis  remains  latent  for  a  number  of  years  and  then 
l)reaks  out  afresh  with  severe  manifestations.  Amongst  patients  with 
diseases  of  the  brain  and  spinal  cord,  we  find  a  great  number  wlio  have 
previously  liad  sy])hilis  and  had  apparently  recovered.  Watraszewski 
lias  stated  that  injuries  to  the  head  or  brain,  which  happen  before  or 
after  syphilis  is  acquired,  predispose  to  the  occurrence  of  syphilis  of 
the  brain  early  in  the  disease.  In  general  one  can  only  be  attacked  by 
syphilis  once  ;  that  is,  a  patient  who  has  once  been  infected  becomes 
unsusceptible  to  the  poison — in  other  words,  immune. 

Immunity  from  Syphilis. — The  imnnmity  from  syphilis  exists  from 
the  time  the  syphilitic  enlargement  of  the  glands  takes  place — indeed, 
as  a  rule,  from  the  time  when  the  primary  initial  sclerosis  first  appears 
(L.  Hudels),  and  generally  lasts  till  the  death  of  the  individual  in 
fpiestion.  Those  who  have  completely  recovered  suifer  only  in  rare 
instances  a  reinfection,  as  in  other  acute  infectious  diseases,  and  these 
reinfections  are  not  unjustly  doubted  by  various  authors. 

The  Soft  Chancre. — The  so-called  soft  chancre  (ulcus  molle,  see  Special 
Surgery),  unlike  the  primary  syphilitic  scleroma,  the  hard  chancre,  is  a  local 
ulcerative  process  which  usually  occurs  on  the  glans  penis,  the  foreskin,  vulva, 
or  labia,  and  may  lead  to  inflammation  and  suppuration  of  the  lymph  glands, 
but  never  produces  the  characteristic,  syphilitic,  constitutional   infection. 


§84.]  SYPHILIS.  433 

Thore  has  been  much  discussion  between  two  parties — the  unitarians  and  the 
dualists— ^as  to  the  relalionshij)  of  tlie  soft  cliancre  to  sypliilis.  At  present  tlie 
dualistic  view  is  the  most  generally  accepted — that  is,  that  the  soft  chancre 
is  an  ulcerative  process,  remaining  local,  and  has  nothing  to  do  with  syphilis. 
But  weighty  authorities  including  Hebra,  Auspitz,  Reder  and  Kassowitz  still 
insist  upon  the  unity  of  the  two  processes.  This  is  not  the  place  to  enter  more 
minutely  into  the  discussion,  and  we  shall  only  state  that  we  also  share  the 
dualistic  teachings  advanced  particularly  by  the  French  physicians,  and  we 
lay  pai'ticular  stress  upon  the  fact  that  the  chief  means  of  distinguishing  be- 
tween the  hard  and  soft  chancre  is  not  the  difference  in  hardness,  since,  as  a 
matter  of  fact,  the  so-called  soft  chancre  may  also  show  induration,  but  that 
the  difference  in  the  clinical  behaviour  is  the  single  and  only  means  of  irre- 
futably proving  that  the  primary  syphilitic  scleroma  and  the  ulcerated  chan- 
cre, which  remains  local,  have  nothing  to  do  with  one  another.  It  is  mainly 
the  long  period  of  incubation  of  the  hard  chancre,  and 'the  impossibility  of 
auto-infection,  which  constitute  the  differences  between  it  and  the  localis(>d 
soft  chancre.  The  latter  does  not  have  this  long  incubation,  and  is  capable 
of  being  inoculated  upon  other  portions  of  the  beai*er's  body. 

Gonorrhoea.— Gonorrhoea  (see  Special  Surgery)  also  has  nothing  to  do  with 
true  syphilis.  Gonorrhoea  is  either  a  simple  or  a  mycotic  (specific)  catarrh 
of  the  urethra  or  of  the  genital  tract,  and  is  produced  by  a  micrococcus,  the 
so-called  gonococcus,  first  discovered  by  Neisser.  Neisser  himself  states  that 
not  every  case  of  gonorrhoea  is  due  to  this  coccus,  but  that  there  is  also  a 
gonorrhoea  which  is  not  mycotic.  Bockhardt  excited  gonorrhoea  with  pure 
cultures  of  the  gonococcus  in  a  paralytic  patient  during  the  terminal  stage  of 
his  cerebral  disease. 

Treatment  of  Syphilis— Treatment  of  the  Syphilitic  Primary  Infection. 

— If  sj'philis  is  a  bacterial  disease,  as  it  undoubtedly  is,  it  would  seem 
a  necessary  part  of  the  treatment  to  extirpate  the  place  of  primary  in- 
fection— that  is,  the  cliancre — as  soon  as  possible ;  and  consequently 
Neisser,  Biiuinler  and  others  have  recently  proposed  a  treatment  of 
this  sort  in  order  to  prevent,  or  at  least  to  modify,  the  constitutional 
manifestations  by  removal  of  the  primary  germ  focus.  On  the  other 
hand,  the  propriety  of  excising  the  primary  syphilitic  scleroma  has 
been  contested  on  the  ground  that  this  syphilitic  primary  infection  is, 
after  it  has  made  its  appearance,  the  expression  of  the  constitutional 
disease,  and  consequently  its  extirpation  is  of  no  avail.  I  consider  this 
view  incorrect ;  it  contradicts  our  present  knowledge  of  tlie  origin  of 
constitutional  disease  from  a  primary  focus  of  infection.  Like  Neisser, 
Biiumler,  and  others,  I  also  try  to  destroy  the  primary  point  of  infec- 
tion in  syphilis  by  excision,  by  the  galvano-cautery,  etc.,  in  every  suit- 
able case  as  early  and  as  energetically  as  possible,  before  the  manifesta- 
tions of  the  constitutional  syphilitic  disease  make  their  appearance.  I 
treat  every  suspicious  ulcer  in  the  same  way,  even  when  its  syphilitic 
character  has  not  been  rendered  certain.     Bjiumler  is  right  in  recom- 


434  INFLAMMATION   AND  INJURIES. 

mending  the  removal  of  the  ah'eady  infected  glands  in  suitable  cases  in 
addition  to  the  excision  of  the  primary  lesion.  Syphilitic  ulcerations 
which  appear  later  are  best  treated  with  dusting  powders,  particularly 
iodoform,  dermatol,  oxide  of  zinc,  bismuth,  or  boric  acid,  after  pre- 
viously cauterising  them  with  solutions  of  carbolic  acid  (1  to  2  alcohol) 
or  chloride  of  zinc  (1  to  8),  caustic  potash,  etc.  Washings  with  bi- 
chloride of  mercury  (0"1  to  100  water),  three-per-cent.  solutions  of  car- 
bolic acid,  etc.,  are  also  to  be  recommended.  The  rest  of  the  treatment 
for  local  syphilitic  disease  is  conducted,  as  far  as  necessary,  according 
to  general  surgical  principles. 

Treatment  of  the  Syphilitic  Constitutional  Infection. — For  the  treat- 
ment of  the  syphilitic  constitutional  infection  we  have  two  remedies  at 
our  disposal — mercury  and  iodine.  Opinions  differ  as  to  the  value  of 
these  substances.  According  to  my  own  experience,  mercury  should 
be  used  in  the  early  period  of  constitutional  syphilis,  and  later  on  iodine 
and  mercury  in  alternation.  The  mercurial  treatment  should  begin  as 
soon  as  the  first  symptoms  of  secondary  syphilitic  disease,  in  the  form 
of  glandular  enlargements,  make  their  appearance.  The  methods  of 
administering  mercury  are  by  inunctions  of  ungt.  hydrarg.,  by  subcu- 
taneous injections  of  the  salts  of  mercury,  and  by  the  internal  use  of 
mercurials. 

Of  the  different  methods  of  treating  syphilis,  the  best  in  my  expe- 
rience is  the  inunction  of  ungt.  hydrarg.  In  the  ti-eatment  by  inunc- 
tion, three  to  five  grammes  (in  adults)  of  blue  ointment  are  rubbed 
daily  into  different  areas  of  skin  for  about  twenty  minutes,  following  a 
definite  order  (both  arms,  the  thigh,  the  forearms,  the  legs,  chest,  abdo- 
men, and  back).  After  all  portions  of  the  body  have  been  inuncted, 
the  patient  then  takes  a  bath  and  begins  the  inunctions  anew,  follow- 
ing the  same  order.  I  usually  employ  three  grammes  for  each  of  the 
first  ten  sittings,  four  for  the  next  ten,  and  five  grammes  for  each  of 
the  next  ten.  The  mouth  must  be  kept  scrupulously  clean,  to  avoid  a 
mercurial  stomatitis.  The  teeth  must  be  cleaned  many  times  a  day 
with  a  soft  toothbrush  wrapped  in  mull,  using  tooth-powder  and  water. 
Every  two  to  three  hours  the  patient  must  gargle  his  throat  with  a  one- 
to  two-per-cent.  solution  of  chlorate  of  potash,  boric  acid,  etc.  Smok- 
ing should  be  absolutely  forbidden.  If,  in  spite  of  all  this,  signs  of 
stomatitis  appear,  greater  care  must  be  bestowed  upon  the  mouth,  or 
eventually  the  dosage  of  mercury  must  be  diminished  or  the  mercury 
must  be  stopped  entirely. 

7.  For  subcutaneous  injection  with  the  hypodermic  syringe  various 
double  salts  are  used,  such  as  mercuric  chloride,  sodium  chloride 
(hydrarg.  chlor.  corros.  O'l,  sodii  chlor.  I'O,  aq.  destil.  lO'O,  one  half 


§84.]  SYPHILIS.  435 

to  one  syringefiil  a  day),  or  albuminate  compounds  of  mercuric  clilo- 
ride ;  O'l  gramme  of  the  selected  com})ound  is  injected  daily  into  dif- 
ferent portions  of  the  body,  particularly  the  breast  and  back,  or  intra- 
muscularly in  the  gluteal  regi(jn.  The  injections  which  used  to  be 
given  daily  were  very  inconvenient,  and  they  are  at  present  made  less 
often — every  five  to  eight  days,  for  example — and  preference  is  given  to 
the  use  of  insoluble  salts  of  mercury,  ])articulcirly  calomel,  hj'drarg. 
oxidum  Havum,  etc.,  which  are  best  injected  intramuscularly  in  the 
gluteal  region.  Injections  of  calomel  (()iJ5  to  ()'2  gramme)  in  glycer- 
ine, oil,  or  salt  water,  at  intervals  of  four  to  eight  days,  are  used  very 
frequently.  Kopp,  Striimpell  and  others  reconmiend  injections  of  an 
emulsion  of  calomel  in  water  with  sodium  chloride  (calomel  vap.  parat. 
5*0,  sod.  chlor.  1'25,  aq.  destil.  50'0,  one  gramme  to  be  injected  once  a 
week,  altogether  four  to  six  times).  Calomel  oil  (1  to  10)  is  exceedingly 
good,  two  syringef uls  on  the  first  day,  and  two  more  fourteen  days  after- 
wards, or  every  eight  days  one  syringef ul  (O'l  gramme  calomel ;  Neis- 
ser,  Doutrelepont,  Bergmann).  Prochorow  recommends  one  to  two  per 
cent,  cyanide  of  mercury  (one  hypodermic  syringeful — altogether  about 
twenty  to  twenty-five  injections).  Mention  should  be  made  of  the 
following  methods  of  injection  :  Hydrarg.  oxid.  nigr.  or  hydrarg.  oxid. 
rubr.  laevig.  1"0,  gummi  arab.  0*50,  aq.  destil.  10"0,  or  1  to  10  ol.  oliv, ; 
a  syringeful  of  this  to  be  injected  altogether  three  to  five  to  seven 
times  at  intervals  of  a  week.  In  a  similar  manner  use  is  made  of  the 
very  excellent  hydrarg.  oxid.  flav.  1*0,  gummi  arab.  0'25,  aq.  destil.  30, 
or  1  to  30  ol.  amygdal.  or  olivse  (Striimpell),  every  M-eek  a  syringeful 
in  the  gluteal  region,  four  to  six  to  eight  times.  These  injections  are 
not  so  painful  as  calomel  injections,  and  the  formation  of  abscesses  is 
more  easily  avoided.  E.  Lang  has  practiced  injections  for  many 
years,  with  the  best  results,  with  oleum  cinereum — i.  e.,  a  fifty-per-cent. 
mixture  of  blue  ointment  with  lanoline  and  olive  oil.  Every  five  to 
eight  days,  O'l  to  0'15  of  a  cubic  centimetre  of  the  ointment  is  injected 
in  the  back  or  rump.  The  salicylate  and  thymolate  of  mercury  have 
also  been  mucli  used  for  injections.  -Tommasoli  praises  the  curative 
action  of  injections  of  the  blood  serum  of  lambs  (2  to  8  cubic  centi- 
metres daily).  This  blood-serum  therapy  of  syphilis  is  analogous  to 
the  treatment  of  other  infectious  diseases  with  the  blood  serum  of  ani- 
mals which  have  been  made  immune  from  the  infectious  disease  in 
question.  The  mercury  injections  are  somewhat  painful,  and  must 
always  be  made  by  the  physician  himself,  and  with  antiseptic  precau- 
tions to  prevent  abscesses.  The  injection  treatment  is  in  all  respects 
very  convenient  and  cheap  for  both  dispensai-y  and  private  practice, 
but  I  doubt  whether  it  is  as  valuable  as  the  inunction  treatment. 


436  INFLAMMATION  AND  INJURIES. 

Internally  tlie  following  preparations  are  especially  used  :  Bichlo- 
ride of  mercury  (0'05  to  O'l  gramme  pro  die)  and  calomel  (0'05  to  O'l 
gramme,  three  times  a  day  in  pill  or  powder).  Calomel  is  also  given 
in  large  doses  (e.  g.,  0*1  to  <J'5  gramme  morning  and  evening),  when  it 
is  desired  to  obtain  the  effects  of  mercury  quickly.  Lustgarten  and 
others  have  recommended  hydrarg.  tannicum  oxydulatum  in  powder  or 
pill  form,  according  to  the  following  formula :  Hydrarg.  tannici  oxyd- 
ulat.  4'0  grammes,  extr.  et  pulv.  liquirit.  q.  s.  ad  pilul.  no.  60 ;  three 
to  five  pills  a  day  for  adults,  for  children  smaller  doses  of  0'02  to  0"03 
gramme.  Gamberini,  Schadeck  and  others  recommend  hydrarg.  car- 
bol.  oxydat.  (hydrarg.  carbol.  oxyd.  1-2  gramme,  extr.  et  pulv.  liqui- 
rit. q.  s.  ut  f.  m.  pilul.  no.  60,  two  to  four  pills  daily).  Schadeck  has 
also  recommended  this  remedy  for  subcutaneous  injections  (hydrarg. 
carbol.  oxyd.  2-0,  mucil.  gummi  4-0,  aq.  destil.  lOO'O,  one  syringeful 
[0-02  of  the  hg.  salt]  every  two  to  three  days).  Kecently  the  salicy- 
late of  mercury  has  been  much  used  internally  (I'O  gramme  in  60  pills, 
three  to  four  pills  daily),  and  for  subcutaneous  injections  (hydrarg. 
salic.  0*20  gramme,  mucil.  gum.  arab.  0'30  gramme,  aq.  destil.  60'0 
cubic  centimetres,  six  to  twelve  injections  to  be  given  within  a  period 
of  two  to  three  days).  After  injections  of  hydrarg.  salicylat.  a  rise  of 
temperature,  night  sweats,  polyuria  and  other  allied  effects  are  ob- 
served (Petersen,  Lesser,  Lang).  Leichtenstern  and  Eich  observed  recur- 
rences in  more  than  thirty  per  cent,  of  the  cases  treated  with  salicylate 
of  mercury,  some  of  them  very  severe,  and  coming  soon  after  the  ter- 
mination of  the  treatment. 

Excretion  of  Mercury— Mercurial  Cachexia. — Accordiug  to  recent  investi- 
gations, mercury  is  exci'eted  mainly  in  the  faeces  and  in  the  urine,  but  in  the 
latter  not  constantly.  The  excretion  of  mercury  in  the  faeces  continues  for 
weeks  or  months  after  the  treatment  has  ceased.  Schuster  found  the  faeces 
free  from  mercury  one  year  after  the  cure.  Vajda,  Paschkis  and  Oberlander 
came  to  the  conclusion  that  mei'cury  is  sometimes  retained  within  the  body 
for  years.  In  former  times,  especially,  the  use  of  mercury  was  dreaded  be- 
cause there  would  occasionally  arise  an  incurable  mercurial  poisoning 
(mercurial  cachexia).  It  is  a  generally  accepted  fact  at  the  present  time  that 
this  trouble  can  be  avoided  with  certainty  by  careful  use  of  the  remedy. 

Iodine  is  suited,  particularly  for  the  late  period,  for  the  gummatous 
inflammations,  though  it  is  also  given  by  many — Zeissel,  for  instance — 
in  the  early  stages.  Lie  only  employs  mercury  late  in  the  disease 
and  in  necessary  cases.  Iodide  of  potassium  or  iodide  of  sodium  is 
given  in  a  dose  of  about  one  to  two  grammes,  seldom  more  (8  to 
10  grammes),  daily,  best  in  aqueous  solution.  In  suitable  cases  very 
large  doses  of  iodide  of  potassium  (20  to  30  grammes  and  more  j)7'o 


g  85.]  LEPROSY.  437 

die)  have  been  administered,  accompanied  by  a  milk  and  meat  diet, 
with  bromide  of  })otassinm  and  antipvrine  to  prevent  tlie  iodi.sm  and 
headache.  ^lany  reconniicnd  the  simuUaneous  use  of  the  iodine  and 
mercurial  treatment,  (iiintz  praises  bichromate  of  potassium,  particu- 
larly for  syphilis  maligna  (one  bottle  of  chromium  water  every  day 
with  0*03  gramme  of  bichromate  of  potassium).  In  syphilis  maligna 
mercury  should  be  used  with  the  greatest  caution.  Iron  and  the  qui- 
nine preparations  are  to  be  recommended,  as  well  as  a  strengthening 
diet,  proper  hygienic  measures,  and  iodide  of  ])Otassium,  together  witli 
a  suitable  local  treatment. 

The  proper  nutrition  of  the  patient  should  be  carefully  attended  to ; 
a  moderate  amount  of  alcohol  should  be  permitted,  and  exercise  in  the 
fresh  air  is  desirable,  etc.  In  the  inunction  treatment,  particularly, 
attention  should  be  paid  to  keeping  the  bowels  regular. 

For  recurrences,  constitutional  treatment,  best  by  inunctions,  should 
always  be  undertaken  again  for  a  time. 

It  is  well  known  that  occasionally,  after  an  apparent  cure  which  may 
have  lasted  years,  severe  local  and  constitutional  manifestations  make 
their  appearance.  For  preventing  this,  Fournier  and  Xeisser  have 
urgently  recommended  the  use  of  mercury  or  iodine  for  one  and 
a  half  to  two  years  at  proper  intervals  after  the  syj)hilis  has  been 
apparently  cured.  When  possible,  I  usually  employ  during  the  first 
two  years  after  the  infection,  even  in  the  cured  cases,  two  courses  of 
inunction  each  half  year  (12  inunctions  of  5  grammes  ungt.  ciner. 
each). 

In  children  with  hereditary  syphilis,  for  example,  it  is  an  excellent 
plan  to  use  mercurial  baths  (2  to  5  grammes  in  a  bath  lasting  half  an 
hour).  The  internal  administration  of  calomel  (O'OOo  to  O'Ol  gramme 
twice  daily)  or  of  bichloride  of  mercury  (0"005  gramme  pro  die)  easily 
produces  disturbances  of  digestion. 

In  the  treatment  of  syphilis,  the  healthy  individuals  with  whom  the 
patient  constantly  comes  in  contact  should  always  be  protected  from 
infection  by  proper  precautions. 

It  is  probable  that  the  mercurial  treatment  of  pregnant  women  can 
also  exert  a  direct  influence  upon  the  syphilis  of  the  foetus  infected  at 
the  time  of  conception,  as  Zweifel,  Gusserow  and  others  have  proved 
that  various  drugs,  like  chloroform,  salicylic  acid  or  iodine  may  pass 
from  the  maternal  into  the  foetal  circulation.  -4 

§  85.  Leprosy  {Lepra). — By  lepra  {elephantiasis  Grcecorum)  or  lep- 
rosy is  understood  a  chronic  infectious  disease  which  is  caused  by  the 
bacillus  leprae,  first  discovered  by  Hansen  and  Xeisser,  and  is  character- 
ised anatomically  by  more  or  less  circumscribed  inflammatory  grow'ths, 


438  INFLAMMATION  AND  INJURIES. 

particularly  in  the  skin  and  nerves.  According  to  A.  Hansen  and 
Bergmann,  lej)ra  is  contagious,  but  not  in  the  ordinary  sense  of  the 
word,  as  the  attendants  upon  such  patients  are  only  very  rarely  affected 
by  the  disease  (Beaven).  Bergmann  found  contagion  to  be  the  excit- 
ing cause  in  sixty  per  cent,  of  the  cases  (one  hundred  and  eight). 
Transmission  by  inheritance  can  only  rarely  be  proved,  the  disease  in 
these  cases  originating  for  the  most  part  in  the  family  by  contact 
from  person  to  person.  Various  authors  deny  the  contagiousness  of 
leprosy. 

The  Lepra  Bacilli  (Fig.  290),  first  demonstrated  by  Armaner  Hansen 
and  then  by  Neisser,  are  small  rods  about  four  to  six  /x  long  and  almost 
one  fi  broad,  and  are  exactly  similar  to  the  tubercle  bacilli,  except  that 
they  are  somewhat  shorter.  The  lepra  bacilli  are  incapable  of  sponta- 
neous movement.  It  is  impossible  as  yet  to  say  whether  the  bright  egg- 
shaped  or  round  uncoloured  spots,  which  come  out 
when  the  bacilli  are  stained,  are  to  be  regarded  as 
spores  or  not.  The  bacilli  are  found  in  the  leprous 
new  growths  in  the  skin,  nerves,  lymph  glands, 
spleen,  liver,  and  testicle,  usually  in  great  numbers, 
,,      .  ,      partly  free  in  the  tissues  and  partly  within  the  cells 

Fig.  206.— Lepra  cells  with      f       ,.'  „     ^    ,,  ,  ,,     „^  _,.   "^  „^„    ^-,   .  _ 

bacilli,  X  700.  (Flii-^'ge.)  m  the  so-called  lepra  cells"  (rig.  296,  JNeisser,  Le- 
loir,  etc.).  These  cells  are,  some  of  them,  large  mo- 
nonuclear cells,  while  others  are  like  leucocytes.  Wynne  found  the  bacilli 
also  in  spindle  shaped  granulation  cells,  and  in  rare  cases  in  giant  cells, 
sometimes  in  great  numbers  (Boinet,  Borrel).  According  to  Unna,  the  ba- 
cilli lie  preferably  in  the  lymph  spaces  of  the  tissues,  and  the  collections  of 
the  bacilli  designated  as  ''lepra  cells"  are  artificial  products,  as  he  thinks 
has  been  proved  by  his  drying  method.  After  decolourising  the  preparation 
in  nitric  acid  and  distilled  water,  be  dehydrated  it,  not  by  alcohol  but  by 
heating  it  over  a  flame,  and  then  clarified  it  with  xylol.  Neisser  and 
Wynne,  in  particular,  have  contested  this  view  of  Unna's. 

The  lepra  bacilli  can  be  stained  in  the  same  manner  as  the  tubercle  ba- 
cilli, but  more  easily  and  rapidly,  by  using,  for  instance,  solutions  like  those 
of  Ziehl  and  Ehrlich.  Gram's  method  is  also  very  useful.  But,  in  contra- 
distinction to  the  tubercle  bacilli,  the  lepra  bacilli,  like  the  majority  of  all 
other  bacteria,  can  be  stained  by  the  simjile  aqueous  solutions  of  our  aniline 
dyes,  particularly  by  fuchsin,  and  methyl  violet  (Baumgarten).  The  artificial 
cultivation  of  the  bacilli  and  their  successful  inoculation  upon  animals  has 
hitherto  been  accompanied  with  difficulties,  and  though  there  can  be  no  doubt 
at  all  as  to  the  specific  pathogenic  significance  of  the  bacilli,  still  a  perfectly 
satisfactory  proof  of  their  specific  action  has  not  as  yet  been  obtained.  Bor- 
doni-Uffreduzzi  was  the  first  to  cultivate  the  bacilli  obtained  from  the  bone 
marrow  of  a  man  dying  of  leprosy  ;  he  cultivated  them  at  the  incubator 
temperature  tipon  hardened  blood  serum  to  which  had  been  added  peptone 
and  glycerine,  and  after  several  days  obtained  band-like,  whitish-grey  colo- 
nies with  indented  borders  made  up  of  bacilli  of  different  lengths,  generally 
with  a  club-shaped  enlargement  at  the  ends.     Inoculations  upon   animals 


§85.]  LKIMIOSY.  4;^9 

■svore  unsuccessful,  because  the  stricitly  parasitic  bacteria  rapidly  lose  tlieir 
virulence  when  cultivated  outside  the  body  (Bordoni-Uffreduzzi,  Baumgar- 
ten).  On  the  other  hand,  inoculations  of  leprosy  by  means  of  particles  of 
tissue  from  leprous  nodes,  made  upon  a  criminal  condemned  to  death,  were 
completely  successful  (Arniug).  Melcber  and  Ortmann  claim  to  have  made 
successful  inoculations  upon  rabbits.  Wesener,  Leloir,  and  others,  on  the 
contrary,  only  obtained  negative  results  in  animals,  and  consequently  are  of 
the  opinion  that  animals  are  immune  from  leprosy.  It  is  certain  that  man 
is  the  chief  sufferer  from  the  leprous  poison  ;  but  how  the  disease  originates 
in  man  and  spreads  is  still  uncertain.  In  the  majority  of  cases  the  disease 
appears  to  spread  from  person  to  person  by  contact — that  is,  by  direct  con- 
tagion ;  inheritance  plays  a  small  part.  Hutchinson's  idea  that  leprosy  is 
spread  by  eating  fish  is  contested  by  a  great  many.  According  to  Hansen, 
leprosy  is  not  inheritable.  Wahl  maintains  that  leprosy  originates  preferably 
in  the  periphery  of  the  body— that  is,  in  the  exposed  skin  and  mucous  mem- 
brane of  the  pharynx  and  larynx,  and  then  very  gradually  extends  to  the 
internal  organs  by  means  of  the  lymph  channels.  According  to  Thoma,  the 
leprous  new  formation  begins  in  the  inner  layers  of  the  skin,  in  the  perivas- 
cular spaces,  and  in  the  immediate  neighbourhood  of  the  smaller  blood-ves- 
sels, and  then  penetrates  into  the  subcutaneous  fatty  tissue,  the  lymph  ves- 
sels and  lymph  glands.  Lepros^y  attacks  almost  all  the  organs  of  the  body, 
but  is  localised  particularly  in  the  skin  and  peripheral  nerves.  Nodules  are 
gradually  formed  like  those  in  tuberculosis.  Large  nerves,  like  the  median 
and  ulnar,  may  swell  into  strands  the  size  of  a  finger.  In  the  nerves  of  a 
patient  with  lepra  anaesthetica  the  bacilli  are  found  in  the  nerve  fasciculi, 
and,  besides  atrophy  and  disappearance  of  the  nerve  fibres,  there  is  an  inter- 
stitial sclerosis  with  sometimes  calcareous  infiltrations.  In  the  nerve  sheaths 
the  leprous  disease  extends  chiefly  towards  the  central  nervous  system,  and 
in  the  diseased  areas  there  may  be  a  complete  destruction  of  the  nerves,  in 
consequence  of  which  a  descending  (not  leprous)  degeneration  takes  place  in 
the  separated  portion  of  the  peripheral  nerves,  involving  both  the  motor  and 
sensory  fibres.  This  explains  why  every  sign  of  leprous  disease  is,  in  certain 
cases,  absent  in  the  peripheral  nerves  of  the  area  of  skin  rendered  anaesthetic  ; 
in  such  cases  the  disease  is  located  in  parts  of  the  nerves  more  centrally  situ- 
ated (Dehio-Gerlach).  Of  the  internal  organs,  especially  the  lymph  glands, 
the  spleen  and  liver  are  diseased.  In  the  blood  usually  no  bacilli  can  be 
demonstrated  ;  but  Kobner,  Thoma  and  Doutrelepont  have  seen  them  in  the 
blood  and  the  capillaries  of  the  liver. 

Occurrence  of  Leprosy. — Leprosy  has  been  known  since  the  earliest  times, 
and  during  the  middle  ages  was  distributed  through  almost  all  the  countries 
of  Europe.  At  present,  in  Europe,  the  disease  is  found  only  in  Sweden, 
Norway,  Finland,  in  the  Russian  Baltic  provinces  and  on  the  coasts  of  the 
Mediterranean  and  Black  Seas,  and  most  frequently  on  the  coasts  of  Norway 
and  in  the  south  of  Spain.  Leprosy  is  widely  distributed  in  different  parts 
of  Asia  (Asia  Minor,  Persia,  China,  India),  in  America  (Central  America, 
north  and  east  coasts),  in  Africa  (Cape  Colony),  and  in  Australia. 

Symptomatology  of  Leprosy. — Leprosy  usually  begins    very   insidi- 
ously, the  duration  of  the  incubation,  according   to  Bergmann   and 


440 


INFLAMMATION  AND   INJURIES. 


others,  generally  being  three  to  four  to  five  years.  A  general  distinction 
is  made  between  leprosy  of  the  skin  and  of  the  nerves,  though,  for 
the  most  part,  they  occur  in  combination.  Leprosy  of  the  skin  is  ob- 
served particularly  on  the  face  and  on  the  hands  and  feet,  and  espe- 
cially on  the  extensor  aspect  of  the  knee  and  elbow  region.  At  first 
there  appear  hyperaemic  spots  (lepra  rubra),  which  either  disappear, 
leaving  behind  a  pigmentation,  or  gradually  grow,  forming  brownish- 
red  nodes  the  size  of  a  walnut  (lepra  tuberosa).  The  nodes,  consisting 
essentially  of  granulation  tissue,  may  remain  stationary  for  a  long 
time,  or  they  may  break  down  and  form  ulcers,  particularly  when  sub- 
jected to  external  injurious  influences.      The  leprous  nodes  develop 

the  most  vigorously  upon  the  face, 
sometimes  singly,  but  generally  in 
groups,  forming  whole  clusters. 
In  consequence  of  the  coalescence 
of  the  nodes  thick  masses  result  on 
the  eyebrows,  the  alge  of  the  nose, 
the  lips  and  chin,  so  that  the  phys- 
iognomy of  such  a  patient  assumes 
an  expression  more  or  less  like  that 
of  an  animal,  and  hence  the  desig- 
nation lepra  s.  facies  leonina,  or 
leontiasis  (Fig.  297). 

The  leprosy  of  the  nerves  (lepra 
nervorum  ansesthetica,  lepra  mu- 
tilans) begins  witli  hypersesthesia 
and  pain  ;  then  anaesthesia  usually 
follows,  with  trophic  disturbances 
consisting  in  the  formation  of  white  and  brown  spots  and  in  atrophy 
of  the  muscles  and  bones.  Motor  paralyses  are  less  common.  As  a 
result  of  the  anaesthesia,  injuries  are  not  noticed  and  lead  to  ulcerative 
processes,  in  consequence  of  which  parts  of  the  fingers  and  toes  may  be 
lost  (lepra  mutilans).  The  nerves  affected  by  leprous  disease  become 
thickened,  particularly  between  the  nerve  fibres  and  in  the  neurilemma, 
as  the  result  of  an  interstitial  sclerosis,  sometimes  combined  with  depos- 
its of  lime,  etc.  Lepra  nervorum  is  essentially  a  degenerative  neuritis 
ascending  from  the  periphery  to  the  centre  (Schultze,  Dehio).  The 
minute  changes  in  the  nerves  occurring  in  lepra  anaesthetica  have  been 
briefly  described  on  page  439. 

After  the  skin  and  nerves,  the  disease  affects  particularly  the 
lymph  glands,  then  the  mucous  membranes,  the  eyes,  nose,  mouth, 
larynx,  and  also  the  liver,  spleen,  and  testicles. 


'^^ 


FiQ.  297.— Lepra  leonina;  forty-year-old  leper 
from  Cape  Colony.     (Fritsch'und  Virchow.) 


S86.1 


ACTINOMYCOSIS. 


441 


Diagnosis. — At  the  begiiiiiin*^  of  the  disease  the  diagnosis  of  lepra 
irun  present  manifold  difiieulties.  The  nodular  form  may  be  confused 
with  syphilis,  the  anajsthetic  with  syringomyelia.  Close  questioning  of 
the  patient,  the  histological  demonstration  of  the  lepra  bacilli,  and 
finally  an  antisyphilitic  course  of  treatment,  may  establish  the  diagnosis 
in  doubtful  cases.  In  syringomyelia,  as  opposed  to  lepra  anaesthetica, 
there  is  usually  only  a  partial  disturbance  of  the  sensory  sphere — for 
instance,  analgesia  and  thermoanaBsthesia,  with  persistence  of  the  tactile 
and  muscular  sense  (P.  A.  Morrow). 

Prognosis. — The  disease  generally  terminates  after  a  varying  length 
of  time — one  to  two  to  live  to  twenty  years — either  with  death  from 
exhaustion  or  from  an  intercurrent 
affection,     not    infrequently    from 
tetanus.     Occasionally  spontaneous 
recovery  takes  place. 

Treatment  of  Leprosy. — Though 
opinions  differ  as  to  the  contagious- 
ness of  lepra,  still  all  authorities  are 
agreed  that  it  is  very  necessary  for 
general  hygienic  reasons  to  isolate 
and  confine  the  patients  in  institu- 
tions for  the  purpose.  Wahl,  Hel- 
lat,  Miinch  and  others  have  vigor- 
ously contended  for  this.  As  yet 
we  do  not  know  any  specific  reme- 
dy for  the  disease,  and  consequent- 
ly the  treatment  is  essentially  a 
symptomatic  one,  consisting  mainly 
in  proper  hygiene,  warm  baths,  and 
the  administration  of  tonics.  In 
febrile  attacks  antipyretics  are  giv- 
en. For  the  local  treatment,  Biden- 
kap,  an  excellent  authority  on  lep- 
rosy, recommends  goa  powder  or  chrysarobin,  which  he  applies  to  the 
nodes  and  spots  on  adhesive  plaster.  In  suitable  cases  surgical  treat- 
ment is  to  be  adopted.  For  lepra  anaesthetica  Mitra  recommends 
nerve-stretching.  Cramer  scrapes  away  the  disease  with  a  sharp  spoon, 
etc.  Massage  of  the  nodes  and  thickened  nerves  is  said  to  be  of  use 
in  many  instances. 

§  86.  Actinomycosis. — By  actinomycosis  is  understood  a  progressive 
ijnflammation  and  suppuration  excited  by  the  ray  fungus  or  actino- 
myces  (Fig.  298),  which  is  observed  particularly  in  cattle,  swine,  and 


Fig.  298. —  Actinomyces  (ray  fungus)  with 
one  branching  tilanient  separated  from 
the  others.     (Ponfick.) 


U2 


INFLAMMATION   AND   INJURIES. 


man,  and   is  transferable  by  inoculation  (Bollinger,  Israel,  Poniick, 

Wolff).      Though  the  aetinorayces  used  to  be  ranked   amongst   the 

mould   fungi    (hyphomycetes),  Bostroem,   in  1885, 

showed  by  a  special  method  of  cultivation  that  it 

belonged  to  the  fission  fungi  (schizomycetes),  and 

was  to  be  regarded  as  a  variety  of  cladothrix  with 

.^■1        branches.     Bollinger  discovered  the  actinomyces  in 

■f  j        cattle,  Israel  in  man,  while  Ponfick  was  the  first  to 

!        prove   the   identity  of   the  actinomycosis  of  cattle 

with  that  of  man. 

The  actinomyces  was  observed  even  earlier  by 
Langenbeck  (18-15)  in  a  vertebral  abscess  in  a  man, 
and  by  Lebert  (1857)  in  a  case  of  thoracic  suppura- 
tion. 

Actinomyces. — In  the  actinomycotic  tumoui's  or  ab- 
scess-like foci  there  are  found  characteristic,  yellow,  solid 
i  ^  granules  the  size  of  a  grain  of  hemp.     If  these  granules 

are  crushed  and  the  preparation  stained  for  half  an  hour 
r-  in  hot,  carbolised  fuchsin,  or  for  twenty-four  hours  in 

an  aqueous  solution  of  gentian  violet,  and  then  placed 
for  ten  to  fifteen  minutes  in  a  solution  of  iodine  in  iodide 
f^  of  potassium,  then  in  alcohol,  etc.,  and  examined  under 

"^  the  microscope,  these  granules  will  be  seen  to  consist  of 

a  characteristic  stellate  arrangement  of  branching  fila- 
ments which  radiate  from  a  common  centre  and  possess 
peculiar  club-shaped  enlargements  (Fig.  298).     In  every 
coloiiy  of  actinomycetes  it  is  possible  at  a  certain  stage, 
according  to  Bostroem,  to  distinguish  three  elements  : 
1,  Club-shaped   formations  ;   2,  a  centrally  placed  net- 
work of  fungous  filaments  of  varying  shape  and  size  ;  3, 
fine,  coccus-like  bodies  (spores),  which   originate  from 
Fig.  299.— Pure     cul-     the   fungous   filaments   and   grow  into   long  rods  and 
ture    (linear     cul-     branching  twigs.     According  to  Wolff  and  Israel,  the 
myces  upon  agar.        significance  of   the  coccus-like   bodies  is  still   obscui'e. 
Domee  states  that  the  spores,  which  can  be  best  exam- 
ined in  potato  cultures  made  at  a  temperature  of  22°  to  24"  C,  originate  by 
transverse  segmentation  of  the  peripheral   filaments,  like  the  arthrospores 
in   the   aspergillus,    for    example.      According  to   Bostroem,  who  was   the 
fii'st  to  make  pure   cultures  of  the  actinomyces,  and   according  to   Moos- 
bi'ugger,  the  central  network  of  filaments  grows  rapidly  and  luxuriantly, 
while  the  nodes  of  the  glands  are  to  be  looked  upon  as  products  of  degen- 
eration incapable  of  further  development.      This  is  contested  by  Partsch. 
M.  Wolff  and  J.   Israel   have   cultivated   the   actinomyces.  in  the  absence 
of  oxygen,  upon  agar  and  in  the  interior  of  raw  hens'  eggs,  and  have  suc- 
cessfully inoculated  these  pure  cultures  upon  rabbits  by  injection  into  the 
peritoneal  cavity.     The  actinomyces  colonies,  when  oxygen  is  cut  off,  form 


(^80.]  ACTINOxMYCOSlS.  443 

upon  af]car  pootiliar  yollowish-whito  vopoiations;  but  when  oxygen  has  free 
access  to  the  colonies  there  are  ol)taine(],  accordiiif^  to  Bostroeni,  character- 
istic ochre-coloured  forms  with  a  chalk-liUe  covering  (Fig.  299).  Pure  cul- 
tures of  the  actinoniyces  grow  vipon  blood  serum,  agar-agar,  glycerine-agar, 
and  gelatine,  as  well  as  in  bouillon ;  growth  upon  potato  takes  place  more 
slowly.  By  injection  of  pure  cultures  (upon  blood  serum,  agar,  and  in  bou- 
illon) into  the  peritoneal  cavity  of  rabbits,  Afanassjew  obtained  typical  actino- 
mycosis. Bostroem  was  not  able  to  transmit  actinomycosis  by  inoculation 
fi-om  man  to  animals,  or  from  animal  to  animal.  From  what  has  been  said, 
it  follows  that  the  actinomyces  grows  in  different  ways  according  to  the  na- 
ture of  the  nutritive  medium  and  the  presence  or  absence  of  oxygen.  It  be- 
longs to  the  polymorphous  bacteria,  or  rather  to  the  cladothrix  species,  and 
may  occasionally  present  itself  as  a  simple  rod,  the  above-mentioned  bulbs 
being  absent  (Ponfick,  Ziegler,  etc.). 

G.  Hesse  found  in  one  case  of  actinomycosis  a  form  of  fungus  which  cor- 
responded neither  to  the  cladothrix  described  by  Bostroem  nor  to  the  Wolff- 
Israel  micro-organism  of  actinomycosis.  G.  Hesse  named  his  fungus  the 
cladothrix  liquefaciens,  on  account  of  its  great  power  for  liquefying  blood 
serum  and  gelatine.  It  is  obligate  aerobic,  germinates  from  spherules  or 
spores,  and  grows  into  long  filaments  with  branches.  In  the  stems  of  the 
filaments  round  spores  are  developed,  which  subsequently  come  away,  leaving 
behind  the  empty  stems. 

Outside  of  the  animal  body  the  actinomyces  grows  by  preference  upon 
plants,  particularly  upon  grains  of  corn. 

The  actinomyces  in  a  section  can  best  be  stained  by  Gram's  method,  first 
with  methyl  violet,  then  with  Bismarck  brown.  Weigert  gives  the  section  a 
preliminary  stain  in  orchilla,  and  then  places  it  in  a  one-per-cent.  aqueous 
solution  of  gentian  violet,  by  which  the  central  network  of  filaments  is 
stained  blue  and  the  bulbous  periphery  ruby  red. 

Occurrence  of  Actinomycosis  in  Animals. — Actinomycosis  is  observed  par- 
ticularly in  cattle,  less  often  in  swine  and  horses.  By  far  the  most  frequent 
site  of  actinomycosis  is  in  the  jaws  of  cattle.  In  this  situation,  according  to 
Bollinger,  Ponfick,  and  Johne,  hemispherical,  simple,  or  composite  elevations 
and  outgrowths  are  formed,  particularly  near  the  angle  of  the  lower  jaw. 
They  cause  the  skin  to  become  thin,  finally  break  through  it,  and  sprout  out 
like  a  fungus.  They  have  a  greyish-yellow  appearance,  and  are  of  lardaceous 
consistency.  Upon  pressure  pus  escapes,  containing  the  characteristic  yellow 
granules  already  mentioned.  The  latter  usually  consist  of  a  great  number 
of  glandular  formations  clinging  together  like  corals.  The  smallest  ele- 
mentary granules  are  macroscopically  scarcely  visible,  and  reveal  a  tangle  of 
filaments,  as  before  remarked,  w^hich  terminate  at  the  periphery  in  club- 
shaped  enlargements  (Fig.  298).  Microscopically  there  is  usually  observed 
in  the  centre  of  the  nodule  the  actinomyces  gland,  with  its  characteristic 
radiate  or  rather  stellate  arrangement,  surrounded  by  epithelioid,  lymphoid, 
and  giant  cells  (Fig.  300).  The  nodules  break  down  later,  and  for  the  most 
part  suppurate,  thus  giving  rise  to  a  correspondingly  extensive  death  of  tissue. 
The  growth  of  the  tumour  is  very  slow;  the  number  of  the  nodular-shaped 
growths  constantly  increases,  and,  after  coalescing  with  one  another,  they 
extend  slowly  into  the  surrounding  parts.     The  tumoui'S  consist  partly  of 


X.^- 


4:U 


INFLAMMATION  AND   INJURIES. 


fibrous  connective  tissue  and  partl}^  of  granulation  tissue,  and  always  con- 
tain the  characteriGtic  smaU  nodules  or  foci  of  suppuration  with  the  fungous 

glands  in  the  form  of  the  above- 


mentioned  granules.  The  foci  of 
suppuration  are  sometimes  small 
and  sometimes  very  extensive. 
In  rare  cases  spontaneous  recov- 
ery takes  place  by  cicatricial  con- 
traction and  calcification.  The 
actinomycetes,  which  usually 
grow  outside  the  animal  body 
upon  plants,  are  taken  into  the 
system  mainly  in  the  vegetable 
food;  but  they  may  also  enter 
through  the  respii'atory  tract  and 
.  soo.-Aotmomycosis  (a)  of  the  ton-ue.  .^-ith  '  any  interruption  of  continuity  in 
surrounding  cellular  intiltration  (cellular  nodule  the  skiu.  The  infection  is  more 
b)  and  tissue  iu  the  process  of  breakinj;  down  .    ,  .  ,,^      t    ■ 

(,),  X  200!    (Ziegler.)  apt  to  occur  m  cattle  hvmg  m 

damp  or  marshy  regions,  partic- 
The  common  start- 


ularly  during  or  soon  after  a  wet  year  (Bostroem). 
ing-point  of  the  infection  is  the  cavity  of  the  mouth  (jaw,  tongue,  pharynx), 
and  may  be  the  result  of  any  slight  injury  to  the  inside  of  the  mouth  pro- 
duced by  stiff  pieces  of  vegetable  food,  or  by  a  carious  tooth,  etc.  Accord- 
ing to  Johue  and  Bostroem,  in  most  of  the  tonsils  of  healthy  swine  there 
are  found  barley  grains  which  have  a  fimgus  on  their  surface  very  similar 
to  the  actinomj'ces.  In  man,  also,  infection  is  most  apt  to  originate  from 
portions  of  plants,  less  often  from  ingestion  of  actinomycotic  meat  or  milk. 
By  growing  into  the  blood-vessels  the  primary  focus  may  give  rise  to  metas- 
tases in  the  various  organs.  Metastases  do  not  usually  oi-iginate  thi-ough  the 
lymph  channels. 

Actinomyces  Musculorum  Suis.— The  ray  fungus  occurring  exclusively  in 
the  muscles  of  hogs,  the  so-called  actinomyces  musculorum  suis,  discovered 
bv  Duncker  in  1884,  is  not  identical  with  the  actinomyces  bovis  s.  homi- 
nis.  Its  radiiite  form  is  similar,  but  its  relationship  to  the  actinomyces  bovis 
s.  hominis  is  still  obscure. 

Actinomycosis  in  Man. — The  occurrence  of  actinomvcosis  in  man 
was  first  carefully  studied  by  J.  Israel  in  1SS5.  He  used  observations 
made  by  himself,  and  the  thirty-eight  cases  of  the  disease  which  were 
then  to  be  found  in  literature.  The  actinomycosis  of  man  can  be 
divided,  according  to  the  point  of  ingress  of  the  infection,  into  five 
groups : 

1.  Cases  in  which  the  fungus  enters  through  the  oral  and  pharyn- 
o-eal  cavities,  forming  a  central  focus  within  the  inferior  maxilla,  or 
becoming  localised  on  the  border  of  the  lower  jaw,  in  the  submaxillary 
and  submental  region,  on  the  neck,  or  the  periosteum  of  the  superior 
maxilla,  or  in  the  region  of  the  cheek. 


%m.] 


ACTIXOMYCOSIS. 


445 


2.  Cases  of  primary  actinomycosis  of  the  respiratory  apparatus, 
with  localisation  in  the  bronchial  mucous  membrane  and  in  the  paren- 
chyma of  the  lungs,  spreading  to  the  pleura,  the  peripleural,  and  pre- 
vertebral tissues,  or  with  extension  to  the  abdominal  wall,  and  finally 
the  formation  of  metastases. 

3.  Cases  of  primary  actinomycosis  in  the  intestinal  tract,  partly  as 
a  superficial  disease  of  the  intestine  and  partly  with  extension  of  the 
process  to  the  peritoneum  and  abdominal  wall  and  the  formation  of 
metastases. 

4.  Cases  in  which  the  point  of  entrance  is  uncertain  (respiratory 
apparatus,  pharynx,  intestine). 

5.  Infection  in  conjunction  with  an  injury  of  the  skin,  cutaneous 
actinomycosis,  particularly  after  injuries  of  the  skin  inflicted  by  foreign 
bodies,  such  as  a  splinter  of  wood,  for  example.  Illich,  counting  in  the 
fifty-four  cases  which  he  saw  in  Albert's  clinic,  has  collected  in  all 
four  hundred  and 
twenty-one  cases 
of  actinomycosis. 
Of  these  there 
were  two  hun- 
dred and  eigh- 
teen in  which  the 
head  and  neck 
were       affected. 


sixteen  of  the 
tongue,  fifty- 
eight  of  the 
lungs,  eighty- 
nine  of  the  ab- 
domen, and  elev- 
en of  the  skin. 
In  twenty  -  nine 
cases  the  point 
where  the  infec- 
tion entered  could 
not  be  proved 
with  certainty. 

Actinomyco- 
sis originates  in  man  chiefly  from  parts  of  vegetable  matter  to  which 
the  fnngus  clings.  Portions  of  vegetable  matter,  especially  barley 
grains,  have  been  repeatedly  demonstrated  in  the  actinomycotic  foci 
(Eostroem,  Illich,  etc.).      Infection  by  eating  actinomycotic  meat,  or 


Fig.  301. — Actinomycosis  of  the  ritrht  side  of  the  neck,  with  numerous 
listulae  leading  to  foci  of  pus,  surrounded  by  indurated  tissue. 
The  patient  is  a  thirty-year-old  peasant.    Eecovery. 


446  INFLAMMATION  AND  INJURIES. 

by  drinking  milk,  is  very  questionable.  The  actinomycosis  of  man 
differs  from  that  of  cattle  by  the  smaller  size  of  the  tumours  and  by 
the  preponderance  of  thickening  and  induration  of  the  tissues.  The 
clinical  pictures  of  actinomycosis  in  man  vary  very  much  according 
to  the  primary  location  of  the  disease.  Sometimes  the  phlegmonous 
type  of  inflammation  with  a  suppurative  breaking  down  preponder- 
ates ;  in  other  cases  the  formation  of  granulations  or  the  induration 
are  most  prominent  (Fig.  301).  The  disease  may  begin  as  a  phleg- 
monous inflammation  about  the  lower  jaw,  forming  epulis-like  tu- 
mours, especially  when  there  are  carious  teeth  present,  as  in  a  case 
which  I  operated  upon  a  short  time  ago.  The  process  may  ex- 
tend from  the  raoutli  or  from  the  jaw  to  the  prevertebral  tissue  of 
the  cervical  and  dorsal  vertebrae  (prevertebral  phlegmon),  w;;[th  sec- 
ondary destruction  of  the  vertebrae.  Not  infrequently  cases  are  ob- 
served which  run  an  acute  course,  presenting  the  picture  of  a  very 
acute  or  even  septic  suppuration,  for  example  in  the  neck,  simulating 
angina  Ludovici  ',  but  this  is  usually  due  to  a  mixed  infection,  as  Partscli 
and  others  have  insisted,  shice  the  actinomyces  does  not  by  itself  ex- 
cite suppuration.  Occasionally  actinomycosis  runs  a  course  resem- 
bling chronic  pygeinia,  with  the  formation  of  multiple  abscesses;  or  the 
disease  begins  in  a  very  insidious  manner,  as  primary  actinomycosis  of 
the  intestine  or  lung,  with  secondary  extension  to  the  peritonaeum, 
heart,  pleura,  and  eventually  the  formation  of  metastases,  etc.  The 
latter  may  become  very  numerous,  as  happened  in  one  case  of  Sonnen- 
burg's,  in  which  the  pleura,  lungs,  the  large  abdominal  organs,  and  the 
skin  of  the  thorax,  abdomen,  back  and  thighs  were  involved.  The 
primary  location  of  the  affection  could  not  be  determined. 

In  a  pure  actinomycosis  without  any  mixed  infection,  such  as  with 
pus  cocci,  the  lymph  glands  are  usuallj^  not  affected,  and  the  metastatic 
infection  takes  place  not  through  the  lymph  vessels  but  through  the 
general  circulation.  Bollinger  saw  one  case  of  primary  actinomycosis 
of  the  brain  in  a  twenty-six-year-old  woman  with  bad  teeth,  who  had 
for  a  long  time  drunk  raw  goats'  and  cows'  milk  as  well  as  eaten  raw 
meat.  The  rather  rare  cases  of  isolated  cutaneous  actinomycosis  some- 
times take  the  form  of  cutaneous  ulcers,  and  sometimes,  of  nodular 
eruptions  like  tubercular  lupus  (Leser). 

Diagnosis  of  Actinomycosis. — The  above-mentioned  characteristic 
yellow  granules  Avliich  are  found  in  the  pus  or  in  the  granulation  tis- 
sue, as  well  as  the  microscopic  demonstration  of  the  fungus,  are  of 
great  importance  in  making  the  diagnosis. 

Prognosis  of  Actinomycosis. — The  prognosis  depends  mainly  upon 
the  situation  of  the  disease,  and  is  always  favourable  in  those  cases  in 


^86.1  ACTINOMYCOSIS.  447 

wliieli  the  diseased  parts  are  accessible  to  surgical  treatment,  for  ex 
ample,  when  they  are  located  in  the  region  of  the  cheeks,  the  jaw, 
the  cavity  of  the  mouth,  the  neck,  etc.  As  Sclilange  has  correctly 
remarked,  actinomycosis  has  a  pronounced  tendency  to  get  well  spon- 
taneously— a  fact  which  is  particularly  noticeable  when,  in  actinomy- 
cosis of  the  neck  or  check,  the  fungi  have  penetrated  beneath  the  skin 
and  then  are  finally  cast  off  as  foreign  bodies.  The  great  majority  of 
all  cases  of  actinomycosis  which  are  accessible  to  surgical  treatment  can 
be  permanently  cured.  The  prognosis  of  actinomycosis  of  the  internal 
organs  is  very  unfavourable. 

Treatment  of  Actinomycosis. — The  treatment  of  actinom^-cosis  is 
wholly  surgical  ;  it  consists  in  extirpation  or  in  incision  followed  by 
energetic  scraping  out  and  disinfection  of  all  accessible  foci.  The 
actinomycosis  which  is  accessible  to  surgical,  that  is,  to  operative  treat- 
ment— for  example,  actinomycosis  of  the  cheeks,  tongue,  jaw,  the  oral 
cavity,  the  neck,  etc. — always  has  a  favourable  prognosis,  as  remarked 
before,  and  a  permanent  cure  is  generally  obtained,  provided  only  the 
actinomycotic  focus  is  thoroughly  removed.  I  operated  on  a  case  of 
actinomycosis  in  a  young  milkmaid  involving  almost  the  entire  lower 
jaw.  The  loosened  teeth  subsequently  became  perfectly  firm,  and  the 
restoration  of  the  lower  jaw  was  very  satisfactory.  In  case  of  infec- 
tion of  the  internal  organs,  with  diffuse  foci  located  in  the  thoracic  or 
peritoneal  cavities,  all  treatment  is  usually  unavailing,  and  even  the 
recognition  of  the  disease  may  present  the  greatest  difticulties. 


CHAPTEK  11. 

INJURIES    AND    SURGIC>L    DISEASES    OF    THE    SOFT    PARTS. 

(skin,  cellular  tissue,  mucous  membranes,  blood-vessels,  lymphatic  system, 
nerves,  muscles,  tendons,  tendon  sheaths,  burs^.) 

Wounds  of  the  soft  parts  (incised  wounds,  punctured  wounds  [phlebotomy],  contused 
and  lacerated  wounds). — Treatment  of  wounds  of  the  soft  parts  (hajmostasis,  tenor- 
rhaphy, neurorrhaphy  [muscle-  and  nerve-regeneration],  suture  of  a  wound,  dress- 
ing).—Treatment  of  the  conditions  following  severe  loss  of  blood  (transfusion, 
salt  infusion). — Burns;  sunstroke;  injuries  from  lightning;  congelation;  gunshot 
wounds  of  soft  parts;  of  bones  and  joints. — Subcutaneous  injuries  of  soft  parts 
(contusion;  subcutaneous  rupture  of  tissue ;  muscular  hernia ;  dislocation  of  ten- 
dons and  nerves). — Inflammations  and  diseases  of  the  soft  parts  (skin,  cellulai* 
tissue,  mucous  membranes,  arteries,  veins,  lymphatic  system,  nerves,  muscles,  ten- 
don sheaths,  bursie). — Gangrene  of  the  soft  parts. 

§  87.  Wounds  of  Soft  Parts. — Of  the  various  kinds  of  wounds  of 
soft  parts,  the  simple  inci.sed  wounds  are  the  ones  wliich  present  most 
clearly  for  the  beginner  the  symptomatology  of  wounds  of  soft  parts, 
and  hence  we  shall  begin  with  them. 

Symptomatology  of  Wounds,  particularly  Incised  Wounds. — The  chief 
symptoms  revealed  by  every  wound  are  pain  in  the  wound,  haemor- 
rhage, and  ga))ing  of  the  edges  of  the  wound. 

Wound  Pain. — The  degree  of  pain  from  a  wound  varies  with  the 
peculiarities  of  the  individual,  the  portion  of  the  body  affected,  and  the 
nature  of  the  injury.  Every  one  knows  that  the  susceptibility  to  pain 
manifested  by  different  people  is  very  variable.  As  regards  the  loca- 
tion of  the  injury,  wounds  of  the  fingers,  lips^  nose,  the  external  geni- 
tals and  bones  are  particularly  painful.  The  division  of  a  sensory  or 
mixed  peripheral  nerve  is  accompanied  by  overpowering  pain,  while 
division  of  the  white  matter  of  the  brain,  in  spite  of  the  numerous 
nerve  fibres  it  contains,  causes  no  pain  to  speak  of.  If  the  division  of 
the  tissues  is  done  rapidly  with  a  sharp  instrument,  the  sensation  of  pain 
is  less  than  when  it  is  done  slowly  and  with  blunt  instruments.  Con- 
sequently it  is  best,  particularly  in  patients  who  are  not  chloroformed, 
to  operate  with  a  sharp  knife,  and  to  divide  the  skin,  with  its  rich 
supply  of  nerves,  rapidly  by  a  single  stroke.  In  battle,  the  tissues  are 
divided  so  quickly  that  the  pain  from  wounds  is  but  slight. 

(448) 


(^87.]  WOUNDS  OF  SOFT   PARTS.  449 

The  subjective  feeling  of  pain  accompanying  tlie  injury  is  less  im- 
portant for  the  physician  and  has  less  bearing  upon  the  treatment 
than  the  other  objective,  perceptible  symptoms — the  haemorrhage  and 
the  gaping  of  the  margins  of  the  Mound. 

Gaping  of  the  Wound. — The  gaping  of  the  wound — that  is,  the 
separation  of  the  divided  soft  parts — is  caused  by  the  tension  and  elas- 
ticity of  the  tissues  and  by  the  contractility  of  the  muscular  elements. 
Hence  it  is  natural  for  the  skin,  fascia,  tendons,  muscles,  vessels,  nerves, 
etc.,  after  being  divided,  particularly  if  in  a  transverse  direction,  to  be 
pulled  asunder. 

Haemorrhage. — The  haemorrhage  (extravasation)  is  the  most  impor- 
tant manifestation  in  the  wound.  In  every  division  of  tissue,  lymph, 
in  addition  to  blood,  is  poured  out  of  the  divided  lymph  spaces  and 
lymph  vessels;  but  the  outflow  of  lymph  is  arrested  partly  by  coagu- 
lation and  partly  by  even  a  very  slight  resistance  in  the  wound,  as  the 
amount  of  pressure  in  the  lymphatic  vessels  is  very  small,  being  no 
greater  than  in  the  surrounding  tissues.  Besides  the  blood  and  the 
lymph,  when  injuries  involve  such  structures  as  glands,  joints,  etc., 
there  may  be  an  escape  of  the  fluid  peculiar  to  these  organs,  such  as 
glandular  secretion,  synovia,  etc. 

We  are  mainly  interested  in  the  extravasation  of  blood  from  the 
vessels — haemorrhage.  This  is  either  arterial,  venous,  or  capillary — i.  e., 
parenchymatous. 

Arterial  Haemorrhage. — Arterial  haemorrhage  is  characterised  by 
bright-red  blood  which  spurts  in  a  smaller  or  larger  stream  from  the 
injured  vessel.  When  there  is  danger  of  asphyxia,  the  colour  of  the 
arterial  blood  is  not  bright  red  but  dark  red,  like  venous  blood  ;  in- 
deed, in  bad  cases  of  asphyxia,  shortly  before  death,  the  blood  has  a 
remarkably  dark-red  or  even  an  actually  black  colour.  Under  such 
conditions,  as  a  result  of  the  threatening  cardiac  paralysis,  the  blood 
pressure  in  the  arterial  system  is  so  lowered  that  the  blood  does  not 
spurt  forth  in  jets,  but  flows  more  continuously  or  suddenly  ceases  en- 
tirely, as  we  have  described,  for  example,  on  pages  26  and  27,  in  case  of 
threatened  death  from  chloroform.  The  bleeding  from  small  arteries 
usually  ceases  of  its  own  accord  from  retraction  and  contraction  of  the 
arterial  walls  and  from  the  pressure  of  the  surrounding  tissues.  In 
larger  arteries  the  bleeding  does  not  stop  of  itself,  and  the  injured  per- 
son bleeds  to  death  unless  the  haemorrhage  is  arrested  by  artificial 
means.  The  amount  of  the  haemorrhage  depends,  of  course,  when  the 
arterv  is  entirely  divided,  upon  the  size  of  the  vessel,  and,  when  partially 
divided,  upon  the  size  of  the  opening  in  the  wall  of  the  vessel.  Longi- 
tudinal wounds  of  an  artery  are  not  so  dangerous  as  transverse  ones, 
29 


45(J     INJURIES  AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

as  the  latter  gape  more,  and  consequently  render  spontaneous  arrest 
of  the  haemorrhage  difficult.  A  transverse  division  of  a  large  artery 
such  as  the  common  carotid,  the  brachial,  or  femoral,  will  be  followed 
by  death  from  loss  of  blood  in  a  short  time,  except  in  the  case  of  punc- 
tured wounds,  or  in  contused  and  lacerated  wounds.  In  contused  and 
lacerated  wounds,  even  in  those  resulting  from  tearing  away  an  extrem- 
itv.  the  haemorrhage  may  be  very  slight.  The  contused  and  lacerated 
vessels  are  crushed,  and,  in  the  case  of  arteries,  the  media  and  intima 
are  rolled  inwards,  while  the  adventitia  is  likewise  twisted  or  pressed 
together;  hence  the  bleeding  is  only  slight.  But  in  all  contused 
wounds  secondary  haemorrhage  very  frequently  occurs  when  the  con- 
tused portion  of  the  vessel  or  the  thrombus  sloughs  off.  Secondary 
haemorrhage  also  readily  results  from  punctured  wounds  of  arteries 
which  have  been  closed  by  a  temporary  contraction  of  the  elastic  arte- 
rial wall,  by  a  blood-clot  or  through  the  wound  in  the  skin. 

Haemorrhage  from  the  Veins. — In  haemorrhage  from  the -veins  the 
dark-red  blood  flows  out  more  continuously,  and  when  a  vein  is  com- 
pletely divided  it  flows  most  readily  from  the  peripheral  end.  In 
large  veins,  when  the  valves  are  insufficient,  or  when  in  the  neighbour- 
hood of  the  injury  large  branches  open  into  the  main  vein,  the  blood 
flows  backwards  out  of  the  central  end.  Under  these  conditions  haem- 
orrhage takes  place  from  both  ends  of  the  divided  vein.  Haemor- 
rhage from  the  large  veins  in  the  neighbourhood  of  the  trunk  is 
particularly  dangerous  to  life  if  aid  is  not  at  hand ;  the  dark-red  blood 
usually  wells  forth  in  great  quantities.  But  patients  have  occasionally 
bled  to  death  even  from  varicose  veins  of  the  leg.  The  reasons  for 
such  severe  haemorrhage  are  that  the  return  flow  of  venous  blood  from 
the  dilated  veins  of  the  leg  is  rendered  difficult  by  the  dependent  posi- 
tion of  tlie  veins  aii'l  by  the  partial  obliteration  of  the  venous  channels 
by  previous  inflammatory  thrombi,  and  that  the  patients  often  have 
absolutely  no  idea  of  how  to  help  themselves.  Under  such  circum- 
stances, instead  of  elevating  the  leg  and  compressing  the  wound  with 
the  finger,  they  use  the  strangest  kind  of  methods  for  arresting  haem- 
orrhage. 

Hsemorrhage  from  Capillaries. — The  haemorrhage  from  tlie  capil- 
laries and  small  veins  usually  ceases  f]^ontaneously  in  consequence  of 
the  retraction  of  their  walls,  and  particularly  because  of  the  coagulation 
of  the  blood  (see  page  292).  It  is  well  known  that  the  blood  which 
leaves  the  vascular  passage  coagulates,  and  a  blood-clot,  a  so-called 
thrombus,  forms  in  the  wound  in  the  vessel  (see  pages  290,  291),  which 
not  only  shuts  off  the  communication  of  the  vessel  with  the  exterior, 
but  also  extends  for  some  distance  into  its  lumen.     In  this  wav  the 


^87.]  WOUNDS  OF  SOFT   PARTS.  451 

luemorrliage  ceases,  provided  the  blood-clot  is  not  washed  away  by  the 
blood  current.  The  thrombosis  takes  place  the  more  ra})idly  and  cer- 
tainly the  less  the  blood  pressure  is  in  the  vessels,  particularly  the 
capillaries  and  small  veins.  But  the  spontaneous  closure  by  a  throm- 
bus of  a  wound  in  an  artery  or  large  vein  which  is  adherent  to  the  sur- 
rouiidinir  parts  is  difficult  or  even  impossible. 

The  Results  of  a  Great  Loss  of  Blood. — After  a  great  loss  of  blood 
there  follows  a  falling  off  of  the  arterial  pressure  and  a  cardiac  weak- 
ness whereby  thronilnis  formation  is  facilitated.  A  severe  haemor- 
rhage is  thus,  in  itself,  more  or  less  hjemostatic  in  its  effects.  In  the 
same  way  luiemorrhage  is  much  diminished  by  transitory  heart  weak- 
ness during  a  fainting  spell,  even  when  due  to  psychic  influences.  As 
a  result  of  severe  haemorrhage  the  blood  itself  is  changed.  It  becomes 
richer  in  colourless  corpuscles,  which  flow  out  of  the  vessels  of  the 
smallest  calibre  where  they  had  accumulated,  and  the  lymph,  with  the 
lymph  corpuscles,  also  streams  with  greater  rapidity  and  in  greater 
quantities  into  the  depleted  vascular  system.  Under  these  circum- 
stances the  coagulability  of  the  blood  increases,  and  this  again  facili- 
tates the  spontaneous  arrest  of  haemorrhage.  If  a  dog  is  bled  to  death 
■  by  repeated  phlebotomies,  the  blood  last  taken  from  the  animal  will 
often  coagulate  almost  immediately. 

Further  Manifestations  Following  Severe  Losses  of  Blood. — The  fur- 
ther symptoms  following  severe  loss  of  blood  consist  in  pallor  and 
coldness  of  the  skin,  particularly  that  of  the  face  and  the  extremities, 
in  great  weakness,  spots  before  the  eyes,  ringing  in  the  ears,  nausea, 
vomiting,  a  feeling  of  anxiety,  vertigo,  fainting  attacks,  etc.  The 
certain  precursors  of  rapidly  approaching  death  from  loss  of  blood  are 
severe  dyspnu?a,  stoppage  of  the  glandular  secretions,  loss  of  conscious- 
ness, dilatation  of  the  pupils,  involuntary  evacuation  of  urine  and 
fseces,  convulsions  which  are  excited  by  sensory  irritation,  sach  as  a 
needle-prick,  etc.  The  high  grade  of  dyspnoea  and  the  convulsions 
preceding  death  from  haemorrhage  are  a  result  of  the  rapid  impoverish- 
ment of  the  brain  in  oxygen,  such  as  occurs  in  strangulation  (Rosenthal). 
The  same  set  of  symptoms,  it  is  well  known,  make  their  appearance  in 
the  Kussmaul-Tenner's  experiment,  when  by  occlusion  of  the  carotid 
and  vertebral  arteries  an  acute  cerebral  anaemia  is  excited,  or  when  the 
return  flow  of  the  venous  blood  is  suddenly  interrupted. 

Powers  of  Withstanding  Loss  of  Blood. — The  power  of  withstand- 
ing loss  of  blood  appears,  to  a  certain  extent,  to  be  subject  to  individ- 
ual variations.  After  severe  loss  of  blood  everv  suro^eon  has  seen  in 
a  relatively  short  time — two  to  three  days — threatening  symptoms 
vanish  in  cases  where  he  expected  certain  death  ;  and  again,  on  the 


452    INJURIES  AND  SURGICAL   DISEASES   OP   THE  SOFT   PARTS. 

other  hand,  some  patients  go  into  collapse  after  the  loss  of  very  little 
blood.  Very  young  children  may  be  endangered  by  an  insignificant 
haemorrhage,  and  weakly  children  a  year  old  have  died  after  a  loss  of 
only  two  hundred  and  fifty  grammes  of  blood.  In  strong  adults,  who 
are  otherwise  healthy,  the  loss  of  half  the  total  amount  of  blood  is  sure 
to  be  fatal.  Women  appear  to  stand  loss  of  blood  better  than  men.  The 
formation  of  new  blood  seems  to  take  place  more  easily  and  rapidly  in 
them  on  account  of  the  periodic  replacement  of  the  blood  lost  in  every 
menstruation  (Landois).  Fat  people  and  old  and  weak  individuals  are 
very  susceptible  to  loss  of  blood.  The  more  rajjidly  the  ha3inorrhage 
takes  place  the  more  dangerous  it  is. 

Death  from  Haemorrhage  observed  in  Experiments  on  Animals.— In  gen- 
eral, the  facts  which  we  have  ascertained  by  bleeding  dogs  to  death  experi- 
mentally are  also  applicable  to  man.  As  much  as  a  quarter  of  their  total 
normal  quantity  of  blood  has  been  withdrawn  from  dogs  by  phlebotomy 
without  causing  the  blood  pressure  in  the  arteries  to  sink  permanently. 
During  the  phlebotomy  the  arterial  pressure,  of  course,  falls  off  rapidly,  and 
the  pulse  becomes  small.  But  very  soon,  even  in  a  few  minutes,  the  pulse 
again  becomes  stronger,  the  blood  pressure  rises,  not  because  the  contents 
of  the  vascular  system  have  correspondingly  increased,  but  simply  for  the 
reason  that  the  arteries  contract  in  consequence  of  the  irritation  of  the  vaso- 
motor centre  in  the  medulla  oblongata  produced  by  the  ana?mia,  and  thus 
accommodate  themselves  to  the  diminished  amount  of  blood  they  contain 
(Landois).  The  anaemia  caused  by  the  loss  of  blood  acts  as  a  stimulant  for 
the  centre  of  the  vasomotor  nerves.  It  overcomes  the  transitory  fall  in 
pressure  following  the  loss  of  a  certain  quantity  of  blood  which  is  within  the 
above-mentioned  limit.  The  rapidity  with  which  the  blood  flows  and  the 
frequency  of  the  cardiac  contractions  remain  the  same  as  before  the  haemor- 
rhage. But  if  more  than  a  quarter  of  its  contents  is  withdrawn  from  the 
vascular  system — a  third,  for  example — the  arterial  pressure  does  not  again 
rise,  but  renjains  lowered,  the  rapidity  of  the  current  decreases,  and  the  con- 
traction of  the  heart  becomes  slower  in  consequence  of  the  incomplete  filling 
of  the  ventricle.  But  as  the  vagus  centre  receives  less  stimulation  in  conse- 
quence of  the  diminished  arterial  pressure,  the  frequency  of  the  pulse  is  usu- 
ally accelerated  (Cohnheim).  At  the  same  time,  a  change  takes  place  in  the 
composition  of  the  blood,  the  water  it  contains  being  increased  by  absorption 
of  the  parenchymatous  liquids  and  by  the  accelerated  flow  of  the  lymph  from 
the  ductus  thoracicus.  As  a  result  of  the  lowered  blood  iH'essure  the  contents 
of  the  capillaries  do  not  transude  any  longer  from  within  outwards,  but  the 
reverse  condition  prevails:  there  ensues  a  diffusion  and  absori)tion  from  with- 
out inwards  (Cohnheim). 

In  man,  a  loss  of  blood  amounting  to  about  one  half  of  the  total  nor- 
mal qnantity  always  proves  fatal ;  but  even  a  moderate  loss,  amount- 
ing to  a  quarter  of  the  total  quantity,  would  give  rise  to  serious  dangers 
for  the  organism  in  a  short  time,  unless  the  blood  lost  were  replaced 


§87.]  WOUNDS  OP  SOFT   PARTS.  453 

by  a  corresponding  regeneration  of  blood.  The  haemorrhages,  which 
are  difficult  to  stop  and  occur  in  bleeders,  as  they  are  called  (see  pages 
57-59),  arc  especially  dangerous. 

Regeneration  of  the  Blood  after  a  Haemorrhage.— If  the  bleeding  does  not 
go  on  to  death  the  blood  is  restored  by  absorption  from  the  tissues  or  from 
tlie  food  taken  in,  the  first  to  be  absorbed  being  the  serum  sanguinis,  with  the 
dissolved  salts,  and  then  the  albumen.  A  longer  time  is  required  to  form 
new  red  blood-corpuscles.  The  great  thirst  following  profuse  haemorrhage 
is  characteristic.  The  patients  eagerly  drink  great  quantities  of  water.  The 
regenerated  blood  is  at  first  abnormally  watery  (hydra^mic)  and  poor  in  cells 
(oligocythannia,  hypoglobulous).  As  a  result  of  the  greater  flow  of  lymph 
into  the  blood  the  number  of  the  white  blood-corpuscles  is  greatly  increased, 
and  then  their  amount  falls  off  ;  the  red  blood-corpuscles  again  attain  their 
usual  number,  and  the  composition  of  the  blood  gradually  returns  to  the  nor- 
mal. We  do  not  as  yet  know  certainly  how  the  restO)'ation  of  the  red  blood- 
corpuscles  takes  place.  The  most  generally  accepted  view  is  that  colourless 
corpuscles  are  being  constantly  formed  in  the  lymph  glands,  in  the  spleen, 
the  bone  marrow,  and  in  the  liver,  and  a  certain  number  of  these  colourless 
corpuscles  change  into  the  red  disks  (Neumann,  Erb).  After  moderate  losses 
of  blood  in  animals,  Buntzen  saw  the  volume  of  the  blood  restored  in  a  few 
hours,  and  when  the  loss  was  severe,  within  twenty-four  to  forty-eight  hours. 
The  red  blood-corpuscles,  after  hsemorrhages  amounting  to  from  11  to  4  4 
per  cent,  of  the  body  weight,  were  again  complete  after  the  lapse  of  seven  to 
thirty-four  days.  The  beginning  of  the  regeneration  was  proved  to  take 
place  after  forty-eight  hours. 

Entrance  of  Air  into  the  Veins. — Amongst  the  dangers  which  may 
follow  an  injury  to  a  vein,  particular  mention  should  be  made  of  the 
entrance  of  air  into  the  vein,  a  matter  which  we  discussed  on  page  60. 

Of  the  other  symptoms  caused  by  wounds,  those  are  of  especial 
importance  which  indicate  division  of  the  muscles,  tendons,  and  nerves, 
or  the  opening  of  a  joint  or  a  cavity  of  the  body.  I  sliall  refer  to  the 
latter  complications  under  Injuries  of  Joints,  and  in  the  Text-Book 
on  Special  Surgery  (injuries  of  the  cranial  cavity,  thorax,  and  abdo- 
men, and  of  the  separate  joints). 

Division  of  Muscles  and  Tendons. — The  symptoms  which  indicate  a 
division  of  muscles  and  tendons  are  very  simple  ;  they  consist  in  dis- 
turbance of  the  function  of  the  affected  muscle,  and,  in  addition,  the 
divided  muscles  and  tendons  can  usually  be  seen  at  once  when  the 
incised  wound  is  carefully  inspected. 

Division  of  the  Nerves. — The  symptoms  following  division  of  the 
peripheral  nerves  (we  omit  incomplete  divisions,  contusions,  and 
pimctures  of  nerves)  consist  likewise  in  a  corresponding  functional 
disturbance  of  the  affected  peripheral  nerve — in  other  words,  in  sen- 
sory and  motor  disturbances. 


45-1:    INJURIES  AND  SURGICAL  DISEASES   OP   THE  SOFT  PARTS. 

Degeneration  of  Nerve  Fibres  cut  oflF  from  their  Centres. — Nerve  fibres 
cut  off  from  communication  with  the  central  nervous  system  after  a 
time  lose  their  excitability  ;  they  undergo  a  fatty,  granular  degenera- 
tion, which  involves  the  entire  separated  portion  of  the  nerve  down  to 
its  finest  peripheral  branches  (Miiller,  Waller).  The  sensory  fibres, 
according  to  Waller,  degenerate  not  in  the  peripheral  but  in  the  cen- 
tral portion  when  the  posterior  root  is  cut  above  the  spinal  ganglion. 
The  spinal  ganglion  consequently  plays  the  same  part  in  the  preserva- 
tion of  the  sensory  fibres  that  the  spinal  cord  does  for  the  motor.  The 
paralytic  degeneration  probably  occurs  simultaneously  in  the  whole 
length  of  the  peripheral  portion,  not  spreading  from  the  point  of  sec- 
tion towards  the  periphery,  nor  beginning,  as  Scliift"  describes  it,  in  the 
peripheral  network.  The  contents  of  the  nerve  finally  disappear  com- 
pletely, and  probably  the  empty  neurilemma  also.  The  connective 
tissue  of  the  nerves  is  the  seat  of  an  inflammatory,  nuclear  prolifera- 
tion. There  is  still  a  division  of  opinion  as  to  whether  or  not  the 
degeneration  likewise  involves  the  peripheral  end  organs,  such  as  the 
tactile  corpuscles,  the  rods  of  the  retina,  the  terminations  of  the  ol- 
factory nerves,  etc.  Recently  F.  Krause  has  carefully  studied  the 
ascending  and  descending  degeneration  of  divided  nerves,  and  he 
states  that  all  the  sensory  fibres  in  the  peripheral  segment  of  the  nerve 
which  are  connected  with  a  trophic  centre  in  the  periphery,  such  as 
Meissner's  tactile  corpuscles,  remain  intact,  Ijut  the  central  segment  of 
the  nerve  undergoes  degeneration.  On  the  other  hand,  all  the  motor 
nerve  fibres  and  the  sensory  fibres  of  the  bones,  periosteum,  joints, 
muscles,  tendons,  and  the  sensory  fibres  terminating  free  in  the  skin 
persist  in  the  central  nerve  segment  and  degenerate  in  the  peripheral 
portion  of  the  nerve.  At  the  same  time  that  these  degenerative  pro- 
cesses are  taking  place  in  the  nerves,  the  muscles  atrophy  and  in  part 
undergo  fatty  degeneration. 

The  disturbances  of  sensation  after  division  of  nerves  are  not  so 
pronounced  as  the  motor-paralytic  manifestations.  If,  for  example,  a 
mixed  nerve  in  the  extremities — such  as  the  median  or  ulnar — is  di- 
vided, the  manifestations  of  motor  paralysis  are  always  exhibited  in  a 
typical  manner,  while  the  sensory  paralysis  may  be  very  slight  or  almost 
completely  absent,  because  the  collateral  anastomoses  of  the  neighbour- 
ing uninjured  nerves  take  up  vicariously  the  conduction  of  the  sensory 
impulses.  There  is  an  intimate  anastomosis  between  the  finer  nerve 
branches  in  the  skin,  particularly  upon  the  fingers,  and  in  the  face. 
The  individual  perceptive  senses  appear  to  behave  differently  after 
injuries.  It  sometimes  happens  that  all  the  senses — that  is,  the  tactile, 
temperature,  and  pain  sense — are  lost  after  division  of  a  nerve,  or  they 


§87.)  WOUNDS  OP   SOFT   PARTS.  455 

are  more  or  less  retained  ;  while  in  still  other  cases  only  the  tactile  sense 
persists  while  the  pain  and  temperature  senses  are  suspended.  Imme- 
diately after  the  injury  the  disturbances  of  sensibility  are  most  pro- 
nounced, and  after  four  to  six  days  the  manifestations  of  sensory 
paralysis  improve  without  its  necessarily  following  that  a  regeneration 
oi  the  nerve  has  occurred  at  the  injured  point.  Indeed,  the  disturbance 
of  sensibility  may  disappear  more  or  less  completely,  though,  in  fact, 
no  union  has  taken  place  between  the  divided  ends  of  the  nerve.  The 
collateral  paths  gradually  take  on  more  and  more  activity,  or  new- 
formed  nerve-±il)res  grow  from  the  uninjured,  collateral  nerves  into 
the  aniBsthetic,  cutaneous  district. 

As  regards  the  motor  disturbances,  the  muscles  supplied  by  any 
particular  motor  or  mixed  nerve  are  always  paralysed  after  division 
of  this  nerve.  The  position  of  the  hand,  for  instance,  after  division  of 
the  musculo-spiral,  median,  or  ulnar  nerve,  is  alwaj-s  a  typical  one  (see 
Special  Surgery).  Variations  from  the  general  rule  of  course  may 
occur  w4ien  there  are  anomalies  in  innervation.  There  is  observed, 
however,  after  nerve  division,  especially  in  the  subsequent  course  of 
the  case,  more  or  less  substitution  in  the  sense  that  other  muscles,  sup- 
plied by  an  uninjured  nerve,  perform  singly  or  in  groups  the  duties 
of  the  paralysed  muscles.  According  to  Letievant,  these  substitutions 
may  act  so  perfectly,  when  occurring  between  the  ulnar  and  median 
nerves,  for  example,  that  it  is  possible  on  superficial  examination  to 
overlook  an  actually  existing  paralysis  of  the  parts  supplied  by  the 
divided  nerve.  Kiister  and  Falkenheim  have  described  analogous 
cases.  If,  after  division  of  a  mixed  or  motor  nerve,  paralysis  is  par- 
tially or  entirely  absent,  the  cause  is  to  be  ascribed,  according  to  ob- 
servations made  upon  such  cases  by  Kraussold,  Spillman,  and  others,  to 
anomalies  of  innervation  or  to  the  persistence  of  undivided  collateral 
nerve  filaments  which  connect  the  central  and  peripheral  stump  of  the 
divided  nerve.  The  further  towards  the  centre  a  motor  or,  rather, 
mixed  nerve  is  divided,  so  much  the  more  extensive  are,  of  course,  the 
symptoms  of  motor  paralysis. 

Of  the  other  symptoms  which  follow  division  of  peripheral  nerves 
I  should  briefly  mention  the  following :  Very  frequently,  indeed 
almost  always,  the  patients  after  division  of  a  nerve  complain  of  a 
marked  sensation  of  cold  in  the  paralysed  district.  Hutchinson  states 
that  the  difference  in  temperature  amounts  to  from  2*2°  to  5°  C.  (4°  to 
9°  F.).  Kraussold  and  Rohden  found  that  the  temperature  in  the 
paralysed  parts  after  division  of  the  ulnar  nerve  was  lowered  as  much 
as  6°  to  9-8°  C.  (10-8°  to  1Y°  F.).  In  rare  cases  the  temperature  in  the 
paralysed  parts  has  been  observed  to  be  elevated   2°  to  5°  C.  (3"6°  to 


456    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

9*^  F.).  (Haym).  Other  manifestations  are  a  burning,  prickling  pain, 
formication,  an  increase  in  the  secretion  of  sweat  or  a  remarkable  dry- 
ness of  the  involved  area  of  skin,  and,  finally,  cutaneous  affections 
such  as  herpes  zoster,  eczema,  pemphigus,  ecthyma  pustules,  disturb- 
ances in  the  nutrition  of  the  skin,  such  as  the  formation  of  eschars, 
ulceration,  or  gangrene,  especially  on  the  finger-tips.  The  skin  is 
ffidematous,  bluish  red,  or  abnormally  pale.  In  the  periosteum  and 
bones  inflammatory  and  trophic  disturbances  are  also  observed.  In 
the  joints  there  are  serous  effusions  taking  the  form  of  chronic  hy- 
drarthrosis or  subacute  articular  rheumatism,  adhesive  joint  inflam- 
mations, now  and  then  terminating  in  a  stiff  joint — anchylosis.  The 
neuroparalj'tic  (neuropathic)  joint  disturbances,  resembling  a  subacute 
articular  rheumatism,  lead  to  a  painful  swelling  of  the  joint,  and  finally 
to  distention  and  subluxation  of  the  articular  surfaces,  to  marked  atro- 
phy of  the  bone,  and  to  destruction  of  the  whole  joint.  All  of  the 
last-mentioned  changes  in  the  bones  and  joints  occur  only  as  the  final 
results  following  an  unhealed  division  of  a  nerve.  After  the  paralysis 
has  lasted  some  time  a  progressive  atrophy  of  the  portion  of  the  body 
in  question  takes  place  not  only  in  the  muscles  and  the  soft  parts  but 
also  in  the  bones.  The  electrical  excitability  of  the  divided  nerves  and 
muscles  decreases  by  degrees,  and  finally  is  lost  entirely. 

I.  Punctured  Wounds. — Punctured,  contused,  and  lacerated  wounds 
present  many  peculiarities,  and  it  is  therefore  necessary  to  study  them 
somewhat  more  in  detail. 

Punctured  wounds  are  produced  by  sharp  or  blunt-pointed  instru- 
ments, such  as  swords,  daggers,  knives,  needles,  splinters  of  glass  or 
wood,  etc.  Arrow  wounds  of  the  Indians,  for  example,  are  described 
in  §  82,  Punctured  wounds  belong,  in  the  majority  of  cases,  to  simple 
wounds,  and  heal  comparatively  quickly  if  the  injury  does  not  involve 
deeply  lying  parts,  such  as  vessels,  nerves,  joints,  or  the  large  cavities 
of  the  body  with  their  contents,  including  the  cranial  cavity,  the  pleural 
or  peritoneal  cavities.  Sharp-pointed  instruments  in  general  produce 
punctured  wounds  with  smooth  borders,  while  blunt-pointed  objects  are 
more  apt  to  contuse  the  borders  of  the  wound.  Punctured  wounds,  as 
a  general  thing,  correspond  in  shape  to  the  instrument  by  which  the 
wound  was  produced — a  fact  which  is  of  especial  importance  in  medical 
jurisprudence. 

In  a  great  number  of  punctured  wounds  the  depth  of  the  wound  is 
disproportionately  great  in  comparison  to  its  length  and  width,  and  the 
nature  of  the  injury  is  not  so  apparent  as  in  incised  wounds.  If  large 
arteries  or  veins  have  been  injured,  the  hsemorrhage  which  appears 
externally  may  be  relatively  slight.     If  a  large  artery  is  punctured,  at 


§87.] 


WOUNDS  OF  SOFT   PARTS. 


457 


the  inomeiit  of  the  injury  a  great  bright-red  stream  of  blood  spurts 
out;  but  after  removal  of  the  instrument  only  a  little  blood  trickles 
from  the  wound,  because  the  puncture  in  the  artery  has  been  closed  by 
the  elasticity  of  the  arterial  wall.  Should  the  haemorrhage  continue 
from  the  artery,  it  does  not  appear  externally,  but  takes  place  into  the 
tissues  surrounding  the  vessel,  because  the  soft  parts  divided  by  the 
puncture  fall  together  again,  and  do  not  permit  the  blood  to  escape  to 
the  surface  of  the  body.  Under  such  conditions  a  large  blood  tumour 
forms,  a  so-called  anjjurysma  traumaticum  or  spurium,  in  contradis- 
tinction to  the  aneurysma  verum,  which  is  a  more  gradually  develop- 
ing, sacculated,  or  spindle-shaped  dilatation  of  an  artery.  In  the 
aneurysma  traumaticum  there  is  heard,  upon  auscultation  with  the 
stethoscope  over  the  blood  tumour  and  so  over  the  point  of  injury,  a 
systolic  hruit  or  murmur  isoclironous  with  the  pulse,  caused  by  the 
outflow  of  the  blood  throngh  the  opening  in  the  artery  into  the  sur- 
rounding tissues.  This  systolic  murmur,  following  a  puncture  in  an 
artery,  ceases  immediately  when  the  artery  involved  is  compressed 
above  the  point  of  injury  or  when  the  hole  in  the  vessel  becomes  closed 
by  a  thrombus.  No  sound  is  heard,  however,  when  the  artery  is  cut 
completely  across.  These  murmurs  are  of  great  diagnostic  importance. 
Punctured  Wounds  of  Veins  and  Arteries  {Aneurysma  Varicosum,  or 
Arterio  -  Ve7iosu7n). — If  an  artery  and  a  vein  are  injured  simultaneously 
by  a  puncture  (as  may  occur,  for  example,  in  phle- 
botomy when  the  point  of  the  knife  is  stuck  too 
deeply  into  the  median  basilic  vein  and  penetrates 
the  brachial  artery  lying  under  the  vein),  there 
may  result  a  permanent  communication  between 
the  artery  and  the  vein ;   a  sack  is  formed  (Figs. 


Fio.  302.— Aneurysma  arterio- venosuni  (A)  at  the  bend  of  the  elbow 
resulting  from  venesection  ;  b,  arteria  brachialis  (Bell).  The  sack 
A  of  the  aneurysm  is  laid  open  (Froriep). 


Fig.  303.  —  Aneu- 
rysma arterio- 
venosum  (Busch). 


302,  303),  into  which  flows  the  blood  of  the  artery  as  well  as  that  of 
the  vein.  This  condition  is  called  varix  aneurysmaticus  or  aneurysmal 
varix,  or,  better  still,  aneurysma  arterio-venosum. 


458    INJURIES   AND  SURGICAL   DISEASES  OP  THE  SOFT   PARTS. 


Technique  of  Phlebotomy,  or  Venesection.— This  is  perhaps  the  best  place 
for  briefly  considering-  blood-letting.  Venesection,  or  phlebotomy,  formerly 
much  used  for  all  sorts  of  diseases,  is  at  present  almost  never  done  in  surg-ical 
practice.     Phlebotomy  is  performed  almost  exclusively  on  the  veins  of  the 

elbow,  pai'ticu- 
larly  the  median 
basilic,  which  is 
generally  the 
best  developed 
(Fig.  304).  It  is 
to  be  noted  that 
the  vena  inedio- 
basilica  crosses 
the  brachial  ar- 
tery, and  at  this 
point  is  only  sep- 
arated from  it  by 
the  very  thin 
aponeurosis  of 
the  biceps  mus- 
cle ;  consequent- 
ly before  the  ope- 
ration it  is  best 
to  feel  for  the 
pulsation  of  the 
artery,  and  to 
open  the  vein 
either  above  or 
below  the  point 
where  they  cross. 
Phlebotomy       is 

performed  in  the  following  manner  :  In  the  first  place,  the  middle  of  the 
(upper)  arm  is  encircled  by  a  bandage,  or  piece  of  folded  cloth,  to  produce 
venous  stasis  and  a  marked  distention  of  the  vein.  The  tourniquet  should 
not  be  applied  so  tightly  as  to  close  the  artery  ;  the  radial  pulse  must  there- 
fore persist.  The  arm  should  hang  down,  to  permit  a  more  complete  filling 
of  the  vein.  The  vein  is  best  opened  with  a  pointed  scalpel  after  the  field  of 
operation  has  been  carefully  scruboed  with  soap,  .shaved,  and  disinfected.  If 
the  outflow  of  blood  is  not  free  it  can  be  made  to  become  so  by  muscular 
contractions — for  instance,  by  opening  and  closing  the  hand.  When  a  sutfi- 
cient  amount  of  blood  has  escaped,  the  wound  is  closed  by  the  finger,  the 
tourniquet  removed,  and  the  small  wound  covered  with  an  antiseptic  dress- 
ing, which  exerts  a  slight  pressure.  This  small  operation  must,  of  course, 
be  carried  out  with  a  careful  observance  of  antiseptic  precautions.  In  the 
preantiseptic  da^^s  suppurative  venous  thrombosis  and  death  from  pyaemia 
were  of  relatively  frequent  occurrence. 

Spontaneous  healing  of  a  Punctured  Wound  in  a  Vessel. — A  puncture 
in  an  artery  can  heal  spontaneously  if  there  is  not  too  much  gaping  of 


Fig.  304.— Venesection  (right  arm  at  the  bend  of  tlie  elhow).     (  Esmarch.) 


§87.]  WOUNDS  OF   SOFT   PARTS.  459 

the  wound.  Tlie  small  opening  is  closed  by  the  contraction  of  the 
elastic  walls  of  the  vessel  or  by  a  blood-clot.  In  the  case  of  largei- 
arteries  the  formation  of  a  blood-clot  closing  the  hole  is  rendered  diffi- 
cult in  consequence  of  the  high  intra-arterial  pressure.  In"  smaller 
arteries,  where  the  pressure  is  not  too  great,  the  coagulum  is  more 
likelv  to  remain  in  position,  and  the  clot  extending  into  the  lumen  of 
the  vessel  may  receive  fresh  layers  from  the  blood  flowing  by  it,  and 
thus  there  can  result  a  complete  closure  of  this  portion  of  the  vessel 
— in  other  words,  a  completely  occluding  arterial  thrombus.  But  in 
all  cases  where  spontaneous  healing  of  a  puncture  in  a  vessel  is  accom- 
plished by  a  clot,  there  is  the  danger  that .  the  latter  may  be  swept 
awav  at  any  time  should  tliere  be  any  considerable  intra-arterial  pres- 
sure, and  thus  a  renewal  of  the  Ijleeding  will  take  place — a  so-called 
secondary  haemorrhage.  Punctured  wounds  of  veins  heal  spontane- 
ouslv  very  readily  by  becoming  closed  with  a  thrombus.  The  blood 
coagnlates  easily  here  on  account  of  the  slight  intravenous  pressure, 
and  the  walls  of  the  veins  collapse  if  not  prevented  from  doing  so  by 
natural  adhesions  to  the  surrounding  parts,  such  as  fascia  or  bones. 
After  veins  have  been  wounded  there  result  extensive  venous  thrombi, 
which,  especially  in  the  preantiseptic  days  of  surgery,  used  to  be  greatly 
dreaded,  as  they  often  underwent  suppuration  with  subsequent  general 
septic  poisoning  fpysemia). 

Punctured  Injuries  of  the  Nerves, — Punctured  injuries  of  the  nerves 
may  either  completely  or.  more  often,  partially  divide  them,  and  are 
of  special  practical  import.  The  extent  of  the  paralysis  caused  by 
the  injury  to  the  nerve  depends  upon  the  number  of  the  nerve  fibres 
which  have  been  divided.  If  tiie  nerve  is  not  cut  entirely  through, 
spontaneous  healing  usually  follows  without  surgical  interference,  in 
case  the  nerve  was  at  the  same  time  not  too  much  contused.  In  one 
instance  I  saw  an  irremediable  paralysis  of  the  ulnar  nerve  follow  a 
punctured  wound  of  the  nerve  made  by  a  steel  pen  tilled  with  ink. 
The  nerve  was  months  afterwards  coloured  black  throughout  a  large 
part  of  its  extent.  Small  foreign  bodies,  such  as  needle  points,  bits  of 
glass,  etc.,  may  become  encapsulated,  and  they  often  give  rise  in  sen- 
sory or  in  mixed  nerves  to  very  painful  cicatrices  and  cicatricial  tu- 
mours (neuromata)  or  to  epileptiform  attacks.  Before  the  attack 
begins  the  patient  usually  feels  a  pain  in  the  cicatrix. 

Punctured  Wounds  of  Joints  and  of  the  Large  Cavities  of  the  Body. — 
During  the  first  few  hours  or  days  after  tlie  injury  there  may  often  be 
doubt  as  to  whether  a  joint  or  a  large  cavity  of  .the  body,  with  one  of 
its  vitally  important  organs,  has  been  injured.  It  is  true  that  punc- 
tured wounds  entering  joints  or  cavities  of  the  body  not  infrequently 


460    IXJrMES   AND   SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

heal  up  without  treatment ;  but  in  other  cases  it  becomes  evident,  after 
the  lapse  of  a  few  clays,  that  the  punctured  wound  has  given  rise  to 
suppuration  in  the  joint,  or  that  some  important  internal  organ  has 
perhaps  received  such  injuries  as  to  cause  death. 

Traumatic  Emphysema. — In  conclusion,  mention  should  be  made  of 
the  occurrence  of  air  in  the  neighbourhood  of  jDunctured  wounds — 
traumatic  emphysema,  as  it  is  called.  If,  after  punctured  wounds,  air 
collects  to  a  greater  or  less  extent  in  and  under  the  skin,  there  will  be 
felt  a  slight  crepitation  in  the  affected  areas.  The  air  can  be  easily 
removed  by  pressing  and  kneading  with  the  lingers.  Traumatic  em- 
physema, or  the  collection  of  air,  especially  in  the  subcutaneous  cellu- 
lar tissue,  may  be  due  to  an  injury  to  an  organ  which  contains  air,  such 
as  the  lung  or  trachea.  After  injuries  of  the  lung  the  air  may  spread 
l)eneath  the  skin  over  the  entire  body  wherever  it  meets  with  the  least 
resistance.  Air  can  also  be  sucked  into  the  wound  from  without  by 
aspiration.  It  is  well  known  that  there  also  occasionally  arises  a  so- 
called  "  spontaneous "  or  primary  emphysema  after  subcutaneous  ex- 
travasations of  blood,  especially  in  fractures  (Velpeau).  According  to 
H.  Fischer,  this  is  due  to  gases  from  the  blood  which  are  set  free  by 
the  action  of  an  acid,  such  as  the  lactic  acid  which  is  present  in  the 
contused  tissues.  This  so-called  spontaneous  emphysema  can  be  pro- 
duced experimentally  in  animals  by  exciting  in  them  an  extensive  ex- 
travasation of  blood,  and  then  injecting  lactic  acid  into  the  latter.  In 
one  case  which  Fischer  observed  the  gas  consisted  almost  entirely 
of  carbonic  acid.  A  careful  distinction  must  be  made  between  the 
various  kinds  of  emphysema  hitherto  described  and  the  emphysema  of 
decomposition — that  is,  the  collection  of  the  gases  of  decomposition  in 
the  rapidly  spreading  putrefactive  processes  which  may  take  place  in 
severe  open  wounds  as  a  concomitant  symptom  of  very  advanced  sepsis, 
and  in  the  so-called  malignant  cedema,  etc.  (pages  333-330). 

Further  Course  of  Punctured  Wounds. — The  further  course  of  punc- 
tured wounds  can  be  inferred  from  what  has  already  been  said  ;  it  de- 
pends essentially  upon 'whether  important,  deeply  situated  organs  such 
as  arteries,  nerves,  joints,  the  thoracic,  peritoneal  or  cranial  cavities, 
with  their  organs,  are  injured  or  not,  and  whether  excitants  of  inflam- 
mation in  the  form  of  bacteria  are  introduced  into  the  wound  by  the 
instrument  inflicting  the  injury,  and,  finally,  whether  a  foreign  body, 
such  as  the  point  of  an  instrument,  is  left  sticking  in  the  depths  of  the 
wound.  If  all  the  complications  which  have  been  mentioned  are 
absent,  then  punctured  wounds  heal  very  rapidly  like  simple  wounds. 
If  substances  which  excite  inflammation  or  bacteria  liave  been  carried 
into  the  wound  bv  the  instrument,  if  a  foreign  bodv  has  been  left  in 


8  87.]  WOUNDS   OF   SOFT    PARTS.  401 

the  wound  and  the  wound  lias  not  received  antiseptic  treatment,  under 
these  conditions  suppuration,  abscesses,  or  a  deep  and  spreading  cellu- 
litis may  follow,  and  possibly  death  from  pyaemia  and  sepsis.  After 
a  simple  needle-prick  of  the  finger  septic  cellulitis  has  been  repeatedly 
observed  which  ran  a  fatal  course,  and  with  such  rapidity  that,  although 
a  disarticulation  of  the  humerus  was  performed  on  the  fifth  or  sixth 
day,  it  was  impossible  to  save  the  life  of  the  patient.  Not  infrequently 
punctured  injuries  heal  superficially  without  suppuration,  and  yet  in 
their  depths  inflammation  and  suppuration  take  place,  especially  if 
a  non-aseptic  body  be  present. 

Behaviour  of  Foreign  Bodies  in  a  Wound.— Amongst  the  foreign  bodies 
which  may  be  left  behind  in  a  punctured  wound  are  broken-off  needle 
points  or  entire  needles,  knife  points,  sword  points,  splinters  of  glass  or 
wood,  etc.  Knife  and  sword  points  are  particularly  apt  to  break  off  after 
penetrating  bones.  Not  infrequently  the  foreign  bodies  remaining  in  the 
wound  heal  in  without  reaction  when  they  were  more  or  less  aseptic,  e.  g., 
clean.  Needles  have  been  found  embedded  in  the  brain  and  heart  (see 
Special  Surgery).  E.  Simon,  while  conducting  an  autopsy  upon  an  adult, 
found  a  pin  healed  up  in  the  brain  which  had  probably  been  introduced 
through  the  open  fontanelle  dm'ing  the  flret  year  of  his  life.  Huppert, 
while  making  the  post-mortem  examination  upon  an  idiot,  found  a  needle  in 
the  heart  which  extended  free  into  the  left  ventricle  five  to  six  lines.  The 
needle  was  enclosed  by  a  membrane  covered  with  endothelium,  and  had 
caused  no  particular  symptoms  during  life.  It  had  been  in  the  heart 
about  five  yeai's.  Foreign  bodies  frequently  leave  their  original  location  ; 
they  wander — i.  e.,  they  are  pushed  on  by  muscular  contraction  and  by  the 
elasticity  of  the  tissues.  They  may  get  into  internal  organs  and  cause  seri- 
ous trouble,  or  after  weeks,  months,  or  years  they  may  reach  the  skin  at  some 
point,  not  infrequently  causing  an  abscess,  from  which  they  are  then  ex- 
tracted. Billroth  removed  a  knitting-needle  almost  a  foot  long  from  the 
inguinal  region  of  a  thirty-year-old  idiot,  whither  it  had  probably  come  from 
the  vagina  or  rectum.  Needles  which  have  been  swallowed  also  pass,  with- 
out causing  trouble,  through  the  walls  of  the  stomach  and  intestine  and  may 
get  into  the  urinary  bladder,  where  they  give  rise  to  a  vesical  calculus  by 
deposition  of  urates  upon  the  needle.  In  another  case,  a  pin  which  had  been 
swallowed  lodged  in  the  oesophagus  and  killed  the  patient  by  puncturing  the 
aorta.  There  are  a  great  number  of  recorded  cases  illustrating  the  healing 
in  and  wandering  about  of  foreign  bodies,  and  I  could  add  to  the  list  a  con- 
siderable number  of  surprising  ones. 

The  healing  in  of  foreign  bodies  is  also  di.scussed  in  §  61. 

II.  Contused  Wounds. — The  contused  wounds  belong  to  the  com- 
plicated wounds ;  the  tissues  are  crushed  by  the  force  applied  by  a 
blunt  object.  Not  infrequently  they  are  a  part  of  very  extensive  in- 
juries in  which  the  soft  parts  and  bones  have  been  reduced  to  a  pulp. 
All  the  various  kinds  of  wounds  produced  by  blunt  instruments  belong 


462    INJURIES  AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

to  the  class  of  contused  wounds ;  such,  for  instance,  are  tlie  wounds 
produced  bj  "  run-over  "  accidents,  hj  the  kick  of  a  horse,  etc.,  also 
the  numerous  machinery  and  railroad  injuries  so  very  common  in 
modern  industries  and  transportation.  Gunshot  wounds  are,  in  the 
main,  contused  and  lacerated  wounds,  and  will  be  discussed  more  fully 
under  Gunshot  Fractures  (§  124).  Wounds  caused  by  bites  likewise 
belong  to  contused  wounds.  Bites  of  rabid  animals  and  poisonous 
snakes  are  described  in  ^§  80  and  81. 

Appearance  of  Contused  Wounds. — Tlie  appearance  of  contused 
wounds  differs  very  essentially  from  that  of  incised  wounds.  The 
borders  of  the  wound  are  not  smooth  and  of  normal  appearance,  but,  as 
a  result  of  the  bruising,  are  infiltrated  with  blood,  bluish-black  in  col- 
our, swollen,  and  often  irregular  in  shape.  The  bloody  infiltration  of 
the  tissues  varies  with  the  amount  of  force  to  which  they  have  been  sub- 
jected ;  not  infrequently  the  extravasated  blood  spreads  to  a  great  dis- 
tance in  the  parts  around  the  wound.  Occasionally  the  borders  of  the 
wound,  or  the  more  deeply  lying  parts,  are  so  crushed  that  they  sub- 
sequently perish.  When  scratched  with  a  knife  no  blood  flows  out,  and 
the  patient  has  lost  all  sensation  in  the  affected  part.  The  appearance 
of  skin  which  has  been  badly  crushed  varies  according  to  the  amount  of 
blood  it  contains  :  it  may  be  red  shading  off  into  bjuish  or  dark  blue, 
violet,  or  white,  and  corpse-like  and  cold  to  the  touch.  Occasionally 
completely  crushed  skin  looks  apparently  normal  and  yet  it  is  dead. 
Not  infrequently  the  gangrene  of  the  skin  does  not  become  evident 
till  several  days  after  the  injury.  In  severe  cases  of  contused  wounds 
the  borders  of  the  wound  and  the  injured  tissues  in  general  are  torn 
into  shreds,  the  skin  is  more  or  less  extensively  stripped  from  the  un- 
derlying parts,  the  fascia,  tendons,  nerves,  and  vessels  are  mangled  ;  in 
short,  the  soft  parts  are  crushed  to  a  pulp  and  the  bones  broken  into 
numerous  fragments,  etc.  But  in  such  bad  cases  of  contused  wounds 
the  integrity  of  the  tissues  is  disturbed  not  only  at  the  point  of  the  in- 
jury, but  also  at  some  distance  from  it,  in  consequence  of  disturbances 
in  nutrition  d.ue  to  the  infiltration  of  blood.  These  changes  in  the 
neighbourhood  of  the  wound  are  not  perceptible  to  the  eye  of  a  layman, 
but  are  recognised  by  the  surgeon,  and  on  account  of  this  bloody  infil- 
tration, if  there  is  any  necessity  for  an  amputation,  he  performs  it  at 
a  point  not  too  near  the  injury. 

Haemorrhage  in  Contused  Wounds. — When  large  arteries  and  veins 
are  injured,  such  as  the  femoral,  brachial,  or  axillary,  the  haemor- 
rhage, as  a  general  thing,  is  slight,  or  may  even  be  entirely  absent,  for 
the  reason  that  the  injured  vessels  are  crushed  at  the  same  time  with 
the  other  parts,  or  subjected  to  torsion,  in  the  same  way  as  described 


§87.J  WOUNDS  OF  SOFT  PARTS.  463 

in  §  28,  for  cliecking  Imeniorrliage.  At  the  same  time,  after  such  severe 
contusions  there  is  a  high  grade  of  nervous  depression,  of  wound- 
stupor  or  slioek  (§  63).  As  a  result  of  this  shock  the  cardiac  activity 
is  reflexly  diminished  and  the  arteries  are  contracted,  and  lience  the 
tendency  to  haemorrhage  from  the  injured  and  contracted  arteries  is 
decreased.  During^  the  next  few  days,  when  the  shock  ])asses  off  and 
tlie  action  of  the  heart  becomes  stronger,  secondary  liaemorrhages  may 
readily  occur  from  the  crushed,  torn,  or  thrombosed  ai-teries,  and  may 
cause  the  death  of  the  patient  unless  prompt  aid  is  at  liand.  It  is  on 
account  of  these  dreaded  secondary  hagmorrhages  after  contusions  that 
patients  with  such  injuries  should  be  carefully  watched.  The  haem- 
orrhages may  occur  on  the  first  to  second  day  with  the  abatement  of 
the  shock,  or  they  come  on  later,  on  the  fifth  to  tenth  day,  and  some- 
times later  still.  The  later  secondary  haemorrhage  may  be  caused  by 
the  sloughing  away  of  the  contused  portion  of  the  wall  of  the  vessel 
which  has  become  necrotic,  or  by  suppuration  of  a  thrombus,  or  by 
erosion  of  the  artery,  as  a  result  of  suppuration  in  its  immediate  vicin- 
i_ty.  But  the  primary  haemorrhage  in  contused  wounds  is  not  alwavs 
slight ;  it  often  enough  happens  that  there  is  a  considerable  amount 
from  both  arteries  and  veins.  This  is  particularly  apt  to  be  the  case 
when  the  arteries  are  incompletely  torn,  so  that  the  injured  vessel  can- 
not  retract  or  contract.  Under  these  conditions  hemorrhages  into  the 
surrounding  tissues  will  also  be  observed,  forming  so-called  traumatic 
aneurysms  similar  to  those  following  punctured  wounds  of  arteries. 

III.  Lacerated  Wounds. — Lacerated  wounds  present  essentially  the 
same  peculiarities  as  contused  wounds.  The  larger  lacerated  wounds 
have,  in  general,  a  mangled  appearance.  Tearing  away  of  entire  ex- 
tremities— the  upper  or  lower,  by  machinery,  for  instance — belong  to 
the  severest  class  of  injuries  which  a  surgeon  ever  sees.  In  such  cases 
the  injured  person  shows  all  the  symptoms  of  severe  shock,  in  conse- 
quence of  which  death  not  infrequently  follows.  Even  when  entire 
extremities  are  torn  away  there  may  be  no  haemorrhage  of  any  impor- 
tance, for  the  reasons  stated  above.  In  the  hospital  at  Zurich  an  arm, 
including  the  scapula  and  clavicle,  has  been  preserved,  which  was  torn 
away  without  causing  death  by  haemorrhage,  as  the  axillarv  artery  was 
twisted  on  itself  as  in  torsion. 

Further  Course  of  Contused  and  Lacerated  "Wounds. — The  further 
course  of  contused  and  lacerated  wounds  depends  upon  the  severity  of 
the  injury,  upon  the  introduction  of  micro-organisms  at  the  time  of 
the  injury  or  subsequently,  and  whether  the  wound  receives  antiseptic 
treatment  at  as  early  a  period  as  possible.  Even  very  badly  contused 
and  lacerated  wounds  may  heal  without  any  marked  secretion  or  sup- 


464    INJURIES   AND  SURGICAL   DISEASES  OF   THE  SOFT  PARTS. 

puration  if  they  remain  covered  by  an  aseptic  Llood-clot  beneath  an 
antiseptic  dressing.  Tlie  time  which  contused  and  lacerated  wounds 
require  for  heahng  is  longer  than  that  necessary  in  other  wounds.  In 
the  case  of  contusions  of  any  gravity,  the  wound  resulting  from  the 
injury  usually  "  purifies  itself  "  from  the  suj^erficial,  mortified,  or  half- 
dead  tissues,  by  giving  off  a  discharge  or  secretion  which  is  at  first 
bloody,  then  serous,  and  finally  purulent.  "When  the  wound  is  treated 
aseptically  the  discharge  has  no  odour,  but  if  putrefactive  changes  take 
place  it  is  discoloured,  dirty,  and  often  has  a  characteristic  smell.  The 
mortified  (gangrenous)  and  half-dead  tissues  are  cast  off  by  suppuration 
— that  is,  at  the  boundary  line  between  the  healthy  and  dead  parts,  at 
the  so-called  line  of  demarcation,  there  ensues  a  vigorous  proliferation 
of  the  tissue  cells  and  a  collection  of  wandering  cells.  Subsequently 
a  cellular  and  vascular  granulation  tissue  forms,  from  the  surface  of 
which  pus  is  given  off  in  large  quantities.  By  this  demarcating  sup- 
puration the  dead  parts  are  separated  from  the  living.  The  casting  oft" 
of  the  dead  tissue  goes  on  with  different  degrees  of  rapidity,  depending 
particularly  upon  the  vascularity  of  the  injured  tissue.  Hence  it  fol- 
lows that  in  the  case  of  dead  portions  of  tendons,  fascia  and  bone,  the 
process  takes  a  particularly  long  time.  Still  there  are  great  individual 
differences  in  this  respect. 

Contused  and  lacerated  wounds  offer,  in  general,  a  favourable  me- 
dium for  bacteria,  especially  the  former.  The  micro-organisms  usually 
enter  the  wound  at  the  moment  of  the  injury — for  example,  when  upon 
a  dirty  street  a  wagon-wheel  passes  over  an  extremity ;  or  the  instru- 
ment which  inflicts  the  injury,  the  dirty  clothes,  or  tlie  skin  of  the  pa- 
tient, are  the  means  by  which  the  bacteria  are  carried  into  the  wound. 
As  a  result  of  the  presence  and  development  of  the  bacteria  in  the 
wound,  the  various  infectious-wound  diseases  can  originate.  These 
have  been  described  in  §  66  et  seq.  After  extensive  contused  wounds, 
those  spreading,  septic  forms  of  cellulitis,  which  we  have  studied  in 
§  70,  are  particularly  apt  to  occur.  If  a  contused  wound  has  cast  off 
its  mortified  layer,  and  has  passed  into  the  stage  of  granulation,  the 
healing  is  ordinarily  assured  if  no  transgression  is  made  of  the  rules  of 
antisepsis. 

The  more  minute  anatomical  changes  which  take  place  in  the  heal- 
ing of  a  wound,  in  the  formation  of  the  scar,  and  the  cicatricial  con- 
tractures, etc.,  have  been  described  in  §  61. 

As  regards  the  course  of  injuries  of  particular  regions  of  the  body, 
I  must  refer  the  reader  to  my  Text-Book  on  Special  Surgery. 

§  88.  The  Treatment  of  Wounds  of  Soft  Parts. — The  treatment  of 
every  fresh  wound  of   the  soft   parts   is  conducted  upon  antiseptic 


1588.]  TIIK  TRKATMENT   OF   WOUNDS  OF  SOFT   PARTS.  455 

principles,  in  tlie  manner  desoribed  in  §  0,  §  20,  and  ^^  44-4!).  The 
treatment  begins  with  a  careful  examination  of  the  wound,  to  deter- 
mine whether  large  vessels,  tendons,  or  nerves  have  been  injured,  or 
whether  a  joint  or  cavity  of  the  l)ody  has  been  0})ened.  Our  first  care 
should  be  the  arrest  of  the  hannorrhage,  as  we  liave  described  in 
§§  27-30.  The  following  brief  description  of  ha^mostasis  will  suffice  : 
On  the  extremities  it  can  be  best  carried  out  with  the  assistance  of 
Esmarch's  artiticial  iscluiimia.  The  wound,  particularly  if  a  punctured 
wound,  must  always  be  enlarged  sufficiently  to  lay  bare  the  point  where 
the  vessel  has  been  injured,  and  to  })ermit  of  its  inspection.  Every 
large  artery  in  the  wound  which  has  been  punctured  or  cut  must  re- 
ceive a  double  ligature — that  is,  the  vessel  must  be  tied  on  the  central 
and  peripheral  side  of  the  injured  point,  as  only  in  this  way  can  sec- 
ondary luemorrhage  be  prevented  from  the  peripheral  end  of  the  ves- 
sel, or  from  the  puncture  in  the  artery  (Rose).  If  only  the  central 
end  of  the  artery  is  ligated,  a  secondary  haemorrhage  could  occur  from 
the  unligated  peripheral  end  of  the  vessel,  or  the  puncture  in  its  wall, 
very  soon  after  the  establishment  of  the  collateral  circulation.  But 
the  central  and  peripheral  ligation  of  the  artery  in  punctured  wounds, 
for  example,  is  not  sufficient.  All  the  branches  given  off  from  the 
vessel  in  the  neighbourhood  of  the  injury  must  also  be  seciu'ed  at  the 
same  time,  if  one  wishes  to  be  perfectly  sure  of  preventing  haemor- 
rhage from  the  puncture  in  the  artery  (Rose).  After  ligating  the  main 
vessel  and  the  branches,  the  injured  portion  of  the  vessel  can  then 
be  extirpated,  though  it  is  not  necessary.  Injuries  of  large  veins  are 
treated  in  essentially  the  same  manner  as  those  of  arteries.  As  regards 
the  special  technique  for  ligating  arteries  and  veins,  I  must  refer  the 
reader  to  ^  30. 

Temporary  Hsemostasis. — Often  enough  the  physician,  especially  in 
the  country,  is  not  so  situated  as  to  be  able  to  immediatel)'  and  perma- 
nently arrest  the  hsTemorrhage,  but  must  be  content  with  provisional 
haemostasis  carried  out  by  some  sort  of  dressing,  in  order  to  transport 
the  patient  to  a  hospital.  The  simplest  means  of  arresting  haemorrhage 
temporarily  consist,  as  already  mentioned  in  §  29,  in  ajjplying  pressure 
upon  the  bleeding  point  by  the  finger,  a,  pressing,  oran  elastic  bandage, 
and  in  applying  pressure  upon  the  afferent  artery  by  the  finger,  by 
tourniquets,  an  elastic  bandage,  Esmarch's  elastic  tourniquet  (§  19), 
and  finally  by  forced  flexion — ^for  example,  of  the  elbow  joint  or  the 
knee  if  the  haemorrhage  takes  place  in  a  region  supplied  by  the 
branches  of  the  brachial  or  popliteal  arteries. 

Further  Treatment  of  Wounds  of  Soft  Parts. — When  the  bleeding 
has  received  the  most  careful  attention,  it  is  advisable  to  examine  the 
SO 


466    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

wound  tlioroiighly  with  antiseptic  precautions  to  determine  whether 
and  to- what  extent  deeply  placed  parts,  such  as  tendons,  muscles,  nerves, 
or  bones,  have  been  injured,  and'whether  the  wound  is  rendered  un- 
clean by  the  presence  of  a  foreign  body.  The  examination  should  be 
performed  as  gently  as  possible,  and  an  especial  warning  should  be 
given  against  the  too  rough  use  of  the  probe.  By  means  of  the  latter 
it  is  easily  possible  to  penetrate  a  thin,  undivided  layer  of  tissue  over 
a  joint,  over  the  peritoni?eum,  the  pleura,  etc.-,  and  thus  change  a  rela- 
tively simple  wound  into  a  complicated  one.  AVe  shall  go  into  the 
treatment  of  penetrating  wounds  of  joints  or  of  the  cavities  of  the  body 
in  another  chapter  (§  123,  Wounds  of  Joints).  If  it  is  found  that  mus- 
cles, tendons,  or  nerves  have  been  divided,  they  must  be  reunited  by 
sutures. 

Tenorrhaphy — Tendon  Suture. — The  best  method  of  performing  te- 
norrhaphy is  AVolfler's.  He  passes  the  suture  through  the  tendon  stumps 
transversely,  about  one  centimetre  from  their  free  ends,  either  oncjeor 
repeatedly,  and  then  ties  the  ends  of  the  sutures  together.  ^AVitzel. 
recommends  the  application  of  a  "  retention  ligature  "  passed  trans- 
versely through  each  stump  of  the  tendon  about  one  centimetre  from 
its  cut  end  ;  by  means  of  these  retention  ligatures  the  tendon  ends  are 
drawn  together  and  then  united  by  catgut  sutures.  Finally,  the  two 
retention  ligatures  are  knotted  together,  and,  if  desired,  the. tendon 
sheath  is  sutured.  Then  follow  drainage  and  closure  of  the  cutane- 
ous wound.  It  is  sometimes  difficult  to  find  the  central  end  of  the 
tendon,  which  retracts  to  a  greater  or  less  extent,  in  consequence  of  the 
contraction  of  the  muscle  attached  to  it,  and  not  infrequently  the  ten- 
don sheath  has  to  be  opened  for  a  long  distance  upwards — best  on  its 
lateral  aspect — to  find  the  central  end.  The  longitudinal  incision  made 
through  the  skin  for  searching  for  the  tendon  stump  should  always 
be  placed  not  over  the  tendon  but  to  one  side  of  it  ;  this  is  the  best 
way  to  avoid  a  subsequent  adhesion  of  the  tendon  to  the  skin.  To 
facilitate  the  finding  of  the  central  end  of  the  tendon,  it  is  also  a  good 
plan  to  explore  its  sheath  with  a  sharp  hook,  with  which  the  tendon . 
may  be  seized  and  drawn  out,  or  the  extremity  may  be  enveloped  by 
an  elastic  bandage  applied  from  the  centre  towards  the  periphery — 
the  reverse  of  the  usual  manner  of  application.  The  muscle  to  which 
the  tendon  belongs  may  also  be  rubbed  or  pushed  down  from  the  out- 
side. Yery  great  difficulty  sometimes  attends  the  discovery  of  the 
central  tendon  stump  in  old  cases  of  tendon  division.  The  retraction 
of  the  central  end,  under  these  circumstances,  is  occasionally  very  con- 
siderable, and  the  above-mentioned  methods  for  discovering  the  central 
stump  of  the  tendon  are  not  successful,  because  the  stump  is  adherent 


;^88.]  THE  TliKATMENT   OP   WOUNDS   OF   SOFT   PARTS.  4G7 

to  the  tendon  slieath.  INradelung  has  advised,  in  such  cases,  that  the 
central  end  of  the  tendon  be  sought  for  by  an  incision  hjcated  on  the 
central  side  of  the  wound,  or  rather  of  the  cicatrix,  and  that  the  tendon 
be  freed  and  pushed  towards  the  periphery  with  a  round-headed  probe, 
or,  perliaps  better,  M'ith  a  long,  half-curved  needle.  For  the  same 
reasons  mentioned  before,  it  is  better  to  make  the  longitudinal  incision 
to  one  side  of  the  tendon  sheath.  If  the  approximation  of  the  two 
tendon  stumps  presents  difficulties  on  account  of  the  tension  being  too 
great,  as  may  be  the  case  when  there  has  been  a  loss  of  substance,  it 
is  advisable  to  cut  a  flap  with  a  pedicle  from  one  or  each  of  the  ten- 
don stumps.  The  ends  of  the  tendon  are  split  up  to  a  point  near  the 
cut  surfaces,  and  the  pedunculated  flaps  thus  formed  whicli  are  still 
attached  to  the  tendon  are  turned  down  into  the  defect  and  united  with 
catgut  sutures.  Portions  of  tendons  taken  from  young  dogs  or  rabbits 
have  been  successfully  engrafted  in  tendon  defects,  and  attempts  have 
been  made  to  repair  losses  of  substance  by  interposing  strands  of  catgut 
(Gluck,  Monod).  But  even  in  cases  where  the  tendon  ends  could  not 
be  united  but  only  drawn  near  one  another,  satisfactory  results  have 
been  observed  as  regards  the  function  of  the  muscle  involved.  In 
such  cases,  fibrous  bands  form  between  the  tendon  stumps,  as  in  te- 
notomy, or  the  stumps  sometimes  become  adherent  to  the  skin,  and  the 
skin  finally  becomes  so  movable  and  extensible  that  it  follows  the 
movements,  or  rather  traction,  of  the  tendon.  Duplay  and  Tillaux 
obtained  a  good  result  by  suturing  the  peripheral  end  of  the  divided 
tendon  of  the  extensor  longus  pollicis  muscle  (the  cut  ends  were  six 
centimetres  apart,  and  hence  could  not  be  united)  into  a  slit  made  in 
the  underlying  tendon  of  the  extensor  carpi  radialis  longior.  Hager 
and  others  have  likewise  successfully  united  the  peripheral  tendon 
stump  with  the  tendon  of  a  neighbouring  muscle  having  a  similar  ac- 
tion, when  direct  tenorrhaphy  could  not  be  carried  out  on  account  of 
too  great  a  distance  between  the  tendon  stumps. 

'  Tenoplasty  for  lengthening  a  Retracted  (Shortened  Tendon). — H, 
Sporon  has  devised  the  following  means  of  lengthening  a  tendon  which 
has  become  shortened  by  the  repair  of  an  injury  of  the  tendon  or 
from  some  other  cause  :  After  exposing  the  tendon  by  a  longitudinal 
incision  some  five  centimetres  in  length,  two  parallel  longitudinal  in- 
cisions of  equal  length  are  made  in  the  long  axis  of  the  tendon,  one 
placed  one  centimetre  higher  than  the  other.  From  the  upper  end  of 
the  higher  incision  and  the  lower  end  of  the  second,  transverse  inci- 
sions are  made  in  opposite  directions  (Fig.  305).  Thus  the  tendon, 
without  being  divided,  can  be  lengthened  an  amount  ecpial  to  the 
combined  lengths  of  the  two  longitudinal  incisions. 


468    INJURIES  AND  SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 


Suture  of  Muscles. — Transversely  divided  muscles  are  united  by  in- 
terrupted catgut  sutures.     In  cases  of  loss  of  muscular  substance — as 
when  a  piece  is  torn  out  of  the  continuity  of  the  muscle — 
pedunculated  tiaps  can  be  turned  down  into  the  defect  and 
united  by  sutures,  as  in  cases  of  defects  in  tendons. 

Transplantation  of  Muscular  Substance  in  Cases  of  Muscu 
lar  Defects. — In  cases  of  loss  of  substance  in  muscles,  Gluck, 
Helferich  and  others  have  proposed  the  implantation  of 
muscular  tissue  taken,  for  example,  from  a  dog.  Accord- 
ing to  the  experiments  of  Magnus  and  Yolkmann,  a  piece 
of  muscle  thus  implanted  always  perishes,  and  is  absorbed 
in  the  same  way  as  an  implanted  portion  of  a  nerve  taken 
from  an  animal.  As  a  general  rule,  therefore,  one  abstains 
from  the  transplantation  of  a  portion  of  nmscle  in  case  of 
Lenlfthenino-  loss  of  muscular  substaucc  ;  it  is  unnecessary  in  small  mus- 
of  a  tendon   (.^1^^  defects,  and  even  when  the  loss  of  substance  is  large 

(Sporon;.  '  .  .    .   , 

the  stump  of  the  muscle  can  become  connected  by  cicatricial 
tissue — a  cicatricial  inscriptio  tendinea,  as  it  were — and  not  suffer  any 
loss  of  function.  Fig.  306  shows  very  well  that  really  extensive  mus- 
cular defects  may  be  so  completely  compen- 
sated for  by  cicatricial  tissue,  that  the  contrac- 
tion of  the  muscle  as  a  whole  is  not  disturbed 
by  the  interposed  cicatrix.  Gluck  has  also 
attempted  to  remedy  losses  of  muscular  sub- 
stance by  the  interposition  of  strands  of  cat- 
gut, as  in  defects  in  nerves  and  tendons. 

Regeneration  of  Muscle.— It  is  well  known 
that  contractile  muscular  substance  has  but  slight 
capabilities  of  regeneration.  Muscular  defects  are 
always  filled  up  by  connective  tissue,  by  cicatri- 
cial tissue,  and  not  by  new-formed  contractile 
muscular  fibres.  But  in  the  neighbourhood  of 
the  cicatrix,  and  in  slight  injuries  and  contusions 
of  muscles,  regenerative  changes  are  observed 
which  have  been  carefully  studied  by  Weber, 
Waldeyer,  Kraske,  and  others.  At  first  an  en- 
largement and  proliferation  of  the  nuclei  of  the 
muscle  fibres  takes  place,  and  large,  mono-  and 
polynuclear  cells  appear,  which  take  the  place  of 
the  muscle  fibres  which  have  disappeared,  and 
fill  up  the  muscular  interstices.  These  prolifer- 
ated nuclei  of  the  old  muscle  fibres  are  the  for- 
mative cells  of  the  new  fibres;  they  arrange  themselves  into  spindle  shaped 
cells  lying  side  by  side,  in  which  \evj  soon  a  fine  longitudinal  fibrillated  stri- 


Fm.  306.— Partial  circular  loss 
of  substance  in  tlie  muscles 
of  the  upper  arm  of  a  twen- 
ty -  two  -  year  -  old  factory 
girl,  resulting  from  a  gan- 
grenous abscess  which  was 
caused  in  her  fifth  year  by 
the  bite  of  an  insect ;  no 
disturbance  of  motion. 
(Uhde.) 


g  »^8.J 


THE   TREATiMKNT  OP   WOUNDS   OF   SOFT   PARTS. 


469 


ation  is  rec(>giiisa])le,  ami  by  the  ciul  of  the  third  week  the  first  traces  of 
transverse  striatiou  iruike  their  app(;arance.  Nauwei-ck,  contrary  to  these 
teachings,  which  have  been  pretty  generally  accepted,  was  never  able  to  prove 
that  the  proliferated  new-formed  muscular  corpuscles  changed  into  muscular 
fibres.  According  to  Nauwerck,  the  new  formation  of  muscular  tissue  takes 
place  in  the  manner  that  E.  Neumann  described;  it  proceeds  from  the  old 
muscular  fibres  by  terminal  and  lateral  bud(Hng,  and  by  longitudinal  cleav- 
age and  segmentation  of  the  old  and  newly  formed  muscular  fibres.  The 
new-formed  muscular  fibres  penetrate  the  cicatrix  to  a  greater  or  less  extent. 
The  freer  the  process  of  repair  is  from  reaction  the  more  complete  is  the 
regeneration.  Transplanted  portions  of  muscle,  as  we  have  said,  never  retain 
their  vitality ;  they  perish  without  exception,  and  are  subsequently  absorbed. 
In  their  place  a  connective-tissue  cicatrix  forms,  which  possesses  to  a  certain 
extent  the  function  of  muscle,  like  every  other  cicatrix  in  muscle. 

Regeneration  of  Tendon  Tissue.— The  regeneration  of  tendon  tissue  after 
division  of  a  tendon  proceeds  partly  from  the  tendon  .sheath  and  partly  from 
the  stump  of  the  tendon.  After  the  lapse  of  two  to  three  days  \igorous  pro- 
liferative changes  and  numerous  caryocinetic  figures  are  observed  in  the  cells 
of  the  tendon  sheath.  The  cells  in  the  stumps  of  the  tendon,  which  degenerate 
in  part  in  the  neighbourhood  of  the  wound,  likewise  on  the  fourth  to  fifth 
day  take  a  share  in  the  healing  process  (Viering).  By  proliferation  of  the 
cells  of  the  tendon  sheath  and  those  of  the  tendon  proper  there  originates  a 
granulation  tissue,  consisting  of  many-shaped  cells,  by  which  the  tendon 
stumps  are  united.  The  granulation  tissue  then  gradually  changes  into  nor- 
mal tendon  tissue. 

Neurorrhaphy.  The  Union  of  Divided  Nerves  hy  Suture. — 
There  are  two  methods  of  performing  nerve  suture  after  a  nerve  has 
been  divided,  for  instance,  in  an  extremity: 

'the  direct  nerve  suture  through  the  substance 

•of  the  nerve  itself,  and  the  indirect  ov  para- 
neurotic  nerve  suture  through  the  connective 
tissue  enclosing  the  nerve  (Fig.  307).  Both 
methods  have  yielded  good  results,  especially 
since  the  introduction  of  antisepsis.  The  asep- 
tic catgut  suture  is  the  most  desirable  for 
neurorrhaphy.  The  direct  nerve  suture  is  best 
performed  as  Wolberg  has  recommended — by 
passing  a  fine  needle,  flattened  laterally, 
through  tlie  ends  of  the  nerve  about  one  cen- 
timetre from  the  cut  surface,  keeping  the  suture  as  superficial  as  possi- 
ble and  not  passing  it  through  the  entire  thickness  of  the  nerve,  so 
that  the  nerve  fibres  are  damaged  as  little  as  possible.  Two  lateral 
sutures  are  more  sparing  of  the  nerve  and  hold  it  more  securely  than 
one  suture  through  the  middle  of  the  nerve  stump.  According  to  ob- 
servations hitherto  made,  direct  nerve  suture  has  never  produced  any 


Fig.  307. — Nerve  suture  passed 
til  rough  paraneurotic  con- 
nective-tissue. 


470    INJURIES  AND  SURGICAL  DISEASES  OF   THE  SOFT   PARTS. 

bad  effects.  The  jxtnmeio'ofie  suture  passes,  as  we  liave  said,  entirely 
outside  of  the  substance  of  the  nerves  themselves  ;  one  suture  is  ap- 
plied laterally  to  the  nerve  through  the  paraneurotic  connective  tissue 
(Fig.  307),  and  then,  if  necessary,  one  is  placed  behind  and  another  in 
front  of  the  nerve,  and  thus  the  nerve  stumps  are  indirectly  brought 
into  contact.  I  have  found  that  a  combination  of  both  kinds  of  nerve 
suture  is  vei-y  advantageous,  particularly  in  cases  where  there  is  some 
tension  after  the  introduction  of  the  sutures.  The  nerves  are,  how- 
ever, so  extensible  and  elastic  that  by  exerting  traction  upon  the  cen- 
tral and  peripheral  stumps  it  is  easy  to  do  away  with  any  tension. 

Secondary  Neurorrhaphy. — In  old  cases  of  divided  nerves,  "  sec- 
ondary neurorrhaphy "  should  always  be  performed.  The  operation 
has  yielded  very  satisfactory  results.  Simon  and  Esmarch  have  suc- 
cessfully performed  neurorrhaphy  ten  to  sixteen  months  after  the 
nerve  has  been  divided,  and  in  one  case  Jessop  improved  the  paralytic 
sj-mptoms  by  suturing  the  ulnar  nerve  nine  years  after  the  injury.  In 
old  cases  of  nerve  division  the  stumps  of  the  nerve  are  sought  for, 
freed  from  the  connective-tissue  adhesions,  and  fresh  surfaces  made  at 
the  ends,  which  are  then  united  by  one  or  two  aseptic  catgut  sutures. 

Operative  Treatment  of  Loss  of  Nerve  Substance. — If  there  is  a  loss 
of  nerve  sul,)stance — a  nerve  defect — rendering  it  impossible  to  unite 
by  sutures  the  widely  separated  ends  of  the  nerve,  various  plans  can  be 
followed.  In  the  first  place,  an  attempt  can  be  made  to  stretch  the 
nerve  by  traction,  so  as  to  make  it  possible  to  unite  the  ends  by  sutures. 
If  this  cannot  be  done,  i.  e.,  if  the  nerve  stumps  cannot  be  brought  suf- 
ficiently near  together,  flaps  with  pedicles  may  be  formed  from  one 
or  both  ends  of  the  nerve,  turned  down  into  the  defect  and  united  by 
catgut  sutures  (autoplasie  net'veuse  a  lamheaux  LetiSvant).  I  practised 
this  method  successfully  upon  the  median  and  ulnar  nerves  three  months 
after  the  injury,  and  the  paralysed  right  hand  of  the  patient  became  so 
useful  that  she  wrote  me  a  letter  of  thanks  a  year  after  the  operation. 
Dittel,  Brenner  and  others  have  also  had  good  results  with  this  method. 

Nerve-grafting. — Letievant  recommends  nerve-grafthu/  (greffe  ner- 
veuse)  for  loss  of  substance  in  nerves.  The  peripheral  end  of  a  divided 
nerve  is  united  with  an  adjoining  nerve  by  freshening  the  latter  on 
one  side  and  fastening  the  peripheral  end  of  the  injured  nerve  in  the 
freshened  area  by  means  of  catgut ;  or  the  peripheral  end  of  the  nerve 
is  inserted  between  the  fibres  of  the  uninjured  nerve.  By  the  use  of 
the  latter  method  Despres  inserted  the  peripheral  end  of  the  median 
nerve  between  the  fibres  of  the  ulnar  nerve,  and  the  patient  recovered 
the  use  of  his  hand.  M.  Gunn  has  experimented  with  the  method 
upon  animals  with  successful  results. 


§88]  THE  TREATMENT   OF  WOUNDS  OF  SOFT   PARTS.  471 

Lobker's  Procedure. — In  a  case  of  loss  of  substance  in  the  flexor  mus- 
cles of  the  foreurui,  involving  the  median  and  ulnar  nerves,  Lobker 
exsected  a  portion  of  bone  subperiosteally  from  the  radius  and  ulnar 
corresponding  to  the  size  of  the  defect,  and  then  united  by  sutures  the 
freshened  stumps  of  the  tendons  and  nerves. 

Transplantation  of  a  Portion  of  Nerve  into  a  Nerve  Defect. — The  trans- 
plantation of  a  piece  of  one  nerve  into  a  nerve  defect  in  another  was 
first  performed  l)y  Philippeaux  and  Yulpian.  They  were  successful  in 
causing  a  portion  of  the  lingual  nerve  to  heal  into  the  hypoglossal. 
The  latter  completely  regained  its  function.  Recently  Gluck  has  re- 
peated these  experiments,  successfully  implanting  a  portion  of  the 
sciatic  nerve  three  centimetres  long,  taken  from  a  dog,  into  a  corre- 
sponding defect  in  the  sciatic  nerve  of  a  rabljit.  Eleven  days  after  the 
operation  the  sciatic  nerve  in  the  rabbit  is  said  to  have  become  capable 
of  conductinor  mechanical  and  electrical  stimulation.  This  uncommonly 
rapid  restoration  of  conductivity  in  a  sutured  nerve,  and  particularly  in 
one  which  had  been  united  by  transplantation,  contradicts  all  the  obser- 
vations hitherto  made  on  this  subject.  In  spite  of  the  perfect  union  of 
the  transplanted  portion  of  nerve,  Johnson,  after  twenty-three  to 
twenty-four  days,  was  unable  to  obtain  a  contraction  of  the  muscles 
supplied  by  the  nerve  in  question  when  he  stimulated  the  latter  with 
the  induction  current  at  a  point  central  from  the  transplantation,  but 
he  did  cause  contractions  by  direct  stimulation  of  the  muscles.  At  all 
events,  so  rapid  a  restoration  of  nervous  conductivity  as  Gluck  de- 
scribes, after  the  transplantation  of  pieces  of  nerve  into  nerve  defects, 
can  probably  occur  in  only  the  most  exceptional  cases.  As  a  general 
thing,  the  nerve  flbres  contained  in  the  transplanted  piece  of  nerve  will 
perish  ;  but  they  prevent  connective  tissue  from  growing  into  the  nerve 
defect,  and  thus  render  it  possible  for  the  nerve  fibrils  which  develop 
from  the  central  end  of  the  nerve  to  readily  find  their  way  to  the  pe- 
ripheral end.  Furthermore,  it  is  my  opinion  that  the  nerve  fibres  in 
the  above^3escribed  pedunculated  nerve  flaps  do  not  persist ;  but  the 
flaps  prevent  connective  tissue  from  growing  into  the  nerve  defect,  and 
in  this  way  merely  facilitate  the  bridging  over  of  the  nerve  defect  with 
newly  formed  nerve  fibres.  Tanlair  has  shown  that  losses  of  nerve 
substance — nerve  defects — can  be  repaired  by  inserting  the  end  of  the 
nerve  into  an  open  decalcified  bone  drain  or  bone  canal.  By  this  means 
the  ingrowth  of  connective  tissue  into  the  nerve  defect  is  prevented, 
and  the  bridging  over  of  the  defect  with  newly  formed  nerve  fibres  is 
facilitated  by  the  presence  of  the  open  canal.  Gluck  bridged  over  a 
defect  five  centimetres  in  length  in  the  musculo-spiral  nerve  by  means  of 
a  bundle  of  catgut ;  a  year  afterwards  the  function  was  entirely  restored. 


472    INJURIES  AND  SURGICAL  DISEASES  OP   THE  SOFT  PARTS. 

Corresponding  to  the  gradual  regeneration  wliich  takes  place  in  the 
injured  part  of  the  nerve  by  the  bridging  of  it  over  with  newly  formed 
nerve  fibres,  the  conductivity  of  a  nerve  after  it  has  been  sutured  only 
returns  after  the  lapse  of  some  time.  Within  some  two  to  four  weeks 
first  sensibility  returns  in  the  afl:'ected  skin  area,  and  then  motility, 
though  in  exceptional  cases  the  improvement  in  sensation  appears 
later  than  that  in  motion.  The  functional  disturbance  of  the  muscles 
gradually  disappears  as  regeneration  advances  from  the  centre  towards 
the  periphery,  and,  as  Etzold  in  particular  has  correctly  stated,  recovery 
takes  place  first  of  all  in  the  parts  which  are  nearest,  while  in  those 
which  are  more  distant  it  comes  back  much  later  and  more  incom- 
pletely, or  these  more  distant  parts  may  remain  permanently  paralysed. 
The  return  of  motility  is  the  only  means  of  determining  whether  or 
not  a  neurorrhaphy  has  been  successful  in  a  nerve  with  motor  and 
sensory  fibres,  inasmuch  as  sensation  may  become  restored  by  means  of 
the  collateral  branches  of  neighbouring  nerves.  From  observations 
hitherto  made,  sixteen  to  nineteen  days  can  be  considered  as  the  earliest 
period  at  which  return  of  motility  begins  after  a  nerve  suture  ;  in  other 
cases  it  began  only  after  the  lapse  of  several  months,  sometimes  ten  to 
twelve.  But  errors  of  observation  are  possible  as  regards  improvement 
in  motility  after  suturing  a  nerve,  because  here  also,  as  we  saw,  the 
muscles  which  are  not  paralysed  may  take  on  the  functions  of  those 
which  are,  and  more  or  less  compensate  for  the  absence  of  activity 
in  the  really  paralysed  muscles.  By  making  a  careful  electrical  ex- 
amination in  such  cases  it  is  possible  to  determine  whether  or  not  the 
neurorrhaphy  has  been  successful. 

After-treatment  of  Tendon  and  Nerve  Sutures. — The  after-treatment 
of  neurorrhaphies  and  tenorrhaphies  consists  principally  in  placing  the 
aftected  portion  of  the  body,  when  possible,  in  such  a  position  that  the 
suture  is  relaxed ;  for  example,  when  the  ulnar  or  median  nerve  has 
been  sutured  above  the  wrist  joint  the  hand  should  be  immobilised 
in  a  strongly  flexed  position  by  an  antiseptic  dressing,  made  possibly 
of  curved  wooden  splints,  or  of  a  properly  bent  wire  splint  like  that 
which  Cramer  advises.  Thie  remainder  of  the  after-treatment  following 
neurorrhaphy  is  very  important,  and  consists  in  the  use  of  electricity, 
massage,  and  methodical  exercise  of  the  affected  muscles. 

The  Procedures  when  a  Neurorrhaphy  is  Unsuccessful. — If  a  neuror- 
rhaphy should  partially  or  entirely  fail,  the  cicatrix  should  be  divided 
and  the  affected  portion  of  the  nerve  examined,  and,  if  possible,  the 
neurorrhaphy  should  be  repeated.  In  one  case  W.  Busch  exposed  the 
affected  part  of  the  nerve  ten  months  after  an  unsuccessful  neuror- 
rhaphy and  found  that  the  nerve  at  the   point  where  it   had   been 


§88.]  THE  TRKAT.MKxNT   OP   WOUNDS  OP  SOPT   PARTS.  473 

sntnred  was  encircled  by  connective  tissue  in  such  a  way  as  to  intei*- 
rupt  the  conduction  ;  lie  freed  the  nerve  from  the  pressure  of  this  con- 
nective-tissue cicatrix,  and  almost  immediately  the  nerve  became 
capable  of  conducting  the  induction  current,  and  directly  after  the 
operation  the  patient  could  perform  active  movements  which  had  pre- 
viously been  impossible.  Likewise  after  fractures  of  the  humerus  W. 
Busch  has  seen  two  cases  in  which  the  musculo  spiral  nerve  was  para- 
lysed by  the  pressure  of  the  callus,  and  in  which  the  paralysis  immedi- 
ately disappeared  after  removal  of  this  pressure.  Both  Socin  and  I 
have  had  similar  experiences.  As  a  matter  of  fact,  it  is  well  known 
that  the  conductivity  of  a  nerve  can  be  easily  destroyed  by  pressure. 

Spontaneous  Regeneration  of  the  Nerve  without  Suturing.— What  clinical 
facts  are  there  which  bear  upon  the  actual  restoration  of  conductivity  in 
nerves  which  have  been  divided  and  not  united  by  suturing  ?  The  observa- 
tions of  Weir  Mitchell,  Morehaus,  Keen  and  others  prove  that  recovery 
takes  place  in  exceptional  cases  after  extensive  injuries  to  nerves  without  the 
nerve  stumps  being  united  by  sutures.  Notta  saw  one  instance  of  spontaneous 
regeneration  within  six  months  after  division  of  all  the  nerves  of  the  (upper) 
arm.  Tiedemann,  in  August,  1827,  exposed  the  brachial  plexus  of  a  dog  in 
the  axilla  and  divided  each  nerve,  excising  from  them  a  piece  two  to  two  and 
a  half  centimetres  long.  Complete  paralysis  of  sensation  and  motion  fol- 
lowed in  the  affected  extremity,  but  in  the  course  of  the  years  1827  and  1828 
sensation  and  motion  returned  entirely.  In  June,  1829,  the  dog  was  killed, 
and  it  was  found  that  the  ends  of  the  nerves  had  been  reunited  by  medullary 
nerve  fibres.  Scliiff  excised  five  centimetres  of  the  vagus  nerve  in  a  dog, 
and  after  several  months  demonstrated  restoration  of  the  conductivity  of  the 
nerve  without  neurorrhaphy.  Langenbeck  and  Hueter  observed  a  restora- 
tion of  conductivity  after  laceration  of  the  brachial  plexus  in  a  Prussian 
officer  who  was  wounded  by  a  cannon  ball  in  the  storming  of  the  Diippeler 
redoubt  on  April  18,  1864.  The  left  lung  was  extensively  injured,  and  the 
first  rib  was  shattered,  as  was  also  a  part  of  the  scapula  and  clavicle.  In 
spite  of  this  severe  injury  the  patient  escaped  with  his  life.  Langenbeck 
again  saw  the  patient  in  September  of  the  same  year,  and  his  arm  was  totally 
paralysed.  After  the  lapse  of  one  year  and  a  half  the  function  of  the  arm 
was  so  far  restored  by  electrical  treatment  that  the  patient  became  again  fit 
for  service,  and  served  as  an  officer  in  the  campaign  of  1866.  He  was  killed 
while  battalion  commander  in  the  battle  of  Worth.  Riedinger,  Krain,  Letie- 
vant  and  others  have  also  observed  recoveries  after  nerve  division  without 
neurorrhaphy.  But  all  these  recoveries  are  rare  exceptions,  and  the  ordinary 
termination  is  iri-eparable  paralysis.  This  is  due  to  the  fact  that  the  nerve 
fibres  which  have  been  cut  off  from  their  centres,  as  we  remarked  before, 
perish  by  fatty,  granular  degeneration,  and  with  them  the  muscles  they 
supply. 

Results  of  Neurorrhaphy.— With  the  aid  of  my  own  and  Wolberg  s  com- 
munications Weissenstein  has  collected  seventy-six  cases  of  neurorrhaphy, 
and  he  believes  that  the  operation  has  been  successful  in  sixty-seven  per 


474    INJURIES  AND  SURGICAL  DISEASES  OP  THE  SOFT   PARTS. 

cent.  Among-st  the  seventy-six  cases  thirty-three  were  secondary  neuror- 
rhaphies, of  which  twenty-four  were  decidedly  successful  and  others  only 
partially  so.  The  return  of  sensibility  began,  for  the  most  jjart,  after  two  to 
four  weeks.  The  earliest  return  of  motility  began  after  sixteen  days,  but 
in  the  majority  of  the  cases  only  after  the  lapse  of  months,  and  twice  it 
required  a  year.  In  one  case  the  paralysed  muscles  regained  their  complete 
usefulness  after  twenty-six  days,  though  most  of  the  cases  took  a  year. 

Regeneration  after  Complete  Division  of  Nerves.— The  regeneration  of  an 
injured  nerve  takes  place  essentially  as  follows:  When  a  nerve  has  been 
completely  divided,  regeneration  proceeds  from  the  central  end  towai'ds  the 
periphery,  and  it  takes  place  the  more  rapidly  the  less  the  interval  between 
the  central  and  peripheral  nerve  stumps,  and  hence  most  rapidly  when  the 
stumps  are  united  by  sutures.  The  newly  developed  nerve  fibres  spring  from 
the  central  stump  of  the  old  nerve,  and,  bridging  over  the  defect,  unite  with 
the  peripheral  stump.  According  to  one  view,  the  old  nerve  fibres  of  the 
peripheral  segment,  after  their  separation  from  the  centre,  x)erish  irrevocably, 
and  the  newly  formed  nerve  fibres  from  the  central  end  grow,  analogously 
to  what  takes  place  in  embryonic  development,  along  the  peripheral  stump 
into  the  muscles  and  skin  (Vanlair).  According  to  another  view,  the  fibres 
of  the  peripheral  stump  do  degenerate,  but  after  the  regenerated  central 
fibres  have  entered  the  peripheral  stumii  its  fibi-es  likewise  take  part  in  the 
regeneration  and  unite  with  the  fibres,  gi-owing  out  towards  them  from  the 
central  end.  (/Both  kinds  of  regeneration  may  occur  at  the  same  time,  and 
the  regeneration  of  the  degenerated  fibres  in  the  peripheral  stump  will 
take  place  the  more  rapidly  the  earlier  the  central  and  peripheral  ends  are 
united  by  sutures.*  After  division  of  a  nerve  in  man  there  has  never  yet 
been  observed  a  direct  union  of  the  divided  nerve-fibres,  a  so-called  prima 
reunio,  with  restoration  of  conductivity  within  seventy  to  eighty  to  ninety 
hours,  as  Grluck  has  observed  it  in  animal  experimentation.  After  the  lapse 
of  about  two  to  three  months,  sometimes  later,  the  regeneration  of,  for  in- 
stance, a  large  nerve  ia  an  extremity,  is  usually  completed.  If  the  nerve 
stumps  are  not  united  by  suture,  and  if  the  distance  between  the  central  and 
peripheral  stumps  is  too  great,  usually  no  regeneration  of  the  nerve  defect 
occurs.  Under  these  conditions  the  central  end  of  thejierve  takes  on  a 
club-shaped  enlargement  from  the  formation  of  new  nerve  fibres  and  new 
connective  tissue.  This  represents  an  attempt  at  regeneration.  The  so- 
called  amputation  neuromata  are  also  examples  of  such  club-shaped  enlarge- 
ments of  the  ends  of  the  divided  nerves.  In  the  most  rare  and  exceptional 
instances  large  nerve  defects,  up  to  five  centimetres  in  extent,  have  been  re- 
stored in  man  and  animals  without  the  nerve  being  sutured.  But,  as  a  gen- 
eral thing,  the  experiments  of  Sticker  and  others  show  that  spontaneous 
regeneration  of  the  nerve  fails  when  the  distance  between  the  nerve  stumps 
amounts  to  one  centimetre. 

Regeneration  after  Incomplete  Division  of  the  Nerve.— In  incomplete 
division  of  a  nerve,  in  contusions,  etc.,  regeneration  usually  takes  place  more 
rapidly.  If  the  conductivity  of  the  nerve  has  been  interrupted  by  compres- 
sion, such  as  would  be  exerted  by  a  bony  tumour,  by  a  callus,  etc.,  imme- 
diate restoration  of  the  power  of  conducting  a  nerve  current  has  been  observed 
upon  relieving  the  pressure.     A  regeneration  of  the  tissues  of  the  brain  and 


§88.J  THE   TREATMP^NT   OF   WOUNDS   OP   SOFT   PARTS.  475 

spinal  cord  never  takes  place  iu  man.     But  Brown-Sequard  has  observed  a 
regeneration  of  a  divided  spinal  cord  in  doves. 

With  the  regeneration  of  the  nerves  the  exeitability  of  the  latter  also  re- 
turns, and,  according  to  Erb,  Ziemssen,  and  others,  the  power  of  conduction 
returns  sooner  than  the  local  excitability;  that  is,  muscular  contractions  will 
at  first  only  occur  when  stimulation  is  applied  above  the  point  of  injury,  and 
not  when  applied  below. 

Histological  Charges  in  Nerve  Regeneration.— Opinions  vary  as  to  the 
changes  which  occur  in  the  regeneration  of  a  nerve.  Injall  cases  the  regen- 
eration begins  in  the  central  end.  'About  the  third  weekTsmall,  pale  processes 
are  seen  projecting  fro7n  the  axis  cylinders— i.  e.,  the  proximal  axis  cylin- 
ders become  prolonged;  ^ hey  grow  outwards,  and  at  the  same  time  divide 
into  two  or  more  tilaments.  '  These  newly  formed  nerve  filaments  become 
longer  and  longer,  and,  according  to  the  investigations  of  Vanlair  and  others, 
they  gi'ow  into  the  skin  and  muscles.  The  young  nerve  fibres,  according  to 
the  views  of  various  authorities,  are  at  the  outset  naked  axis  cylinders,  and 
then  subsequently  become  covered  by  the  sheath  of  Schwann.  The  state- 
ments made  by  some  authors,  that  the  young  nerve  fibres  are  formed  from 
connective-tissue  cells  or  colourless  blood-corpuscles,  contradict  all  our  other 
histogenetic  views.  According  to  Biingner,  the  regeneration  of  the  injured  ] 
nerves  proceeds  from  the  nuclei  and  the  protoplasm  of  the  sheath  of  \ 
Schivann.     They  are  to  be  regarded  as  the  true  neuroblasts. 

According  to  the  investigations  of  many  authoi-ities,  as  we  have  said, 
analogous  regenerative  changes  in  the  degenerated  fibres  also  take  place  in 
the  peripheral  nerve  stump,  but  much  later  than  in  the  central  stump.  The 
newly  developed  central  and  peripheral  nerve  fibres  grow  towards  each  other 
and  unite.  The  regenerative  changes  in  the  old  degenerated  fibres  in  the 
peripheral  nerve  segment  are  disputed  by  some  observers,  as  we  have  re- 
marked. As  a  matter  of  fact,  it  is  very  diSicult  to  distinguish  histologically 
the  regeneration  and  degeneration  which  go  on  side  by  side  in  the  i^eripheral 
nerve  stump.  Mayer  has  made  the  important  observation  that  I'egenerative 
and  degenerative  changes  occur  even  in  perfectly  normal  nerves. 

Only  those  fibres  which  remain  connected  with  their  centres  are  capable 
of  regenerating  themselves.  The  so-called  regeneration  autogeniqne,  long 
insisted  upon  by  Vulpian — that  is,  the  independent  regeneration  of  a  portion 
of  nerve  cut  off'  from  its  centre — is  founded  upon  an  error,  as  Vulpian  him- 
self has  admitted. 

The  works  treating  of  nerve  regeneration  are  very  numerous.  Cruik- 
shank,  exi:)erimenting  on  animals,  was  the  flj'st  to  observe,  in  1776,  complete 
regeneration  of  divided  nerves.  References  to  the  most  important  literature 
on  the  subjects  of  nerve  injuries  and  neurorrhaphy  will  be  found  in  a  paper 
on  these  matters  in  the  Archiv  fiii*  klin.  Chir.,  Bd.  xxjii. 

Further  Treatment  of  Wounds  of  Soft  Parts. — Tlie  further  treatment 
of  wounds  of  soft  parts  consists  in  the  most  careful  disinfection  of  tlie 
wound  aud  in  the  removal  of  any  foreign  body  w'liich  has  entered  it, 
such  as  sand,  dirt  of  every  description,  pieces  of  glass,  points  of  in- 
struments, bullets,  etc.      By  using  Esmarch's  artificial  ischsemia  the 


476    INJURIES  AND   SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

search  for  foreign  bodies  will  be  greatly  facilitated.  "VVe  shall  return 
to  the  extraction  of  bullets  in  the  chapter  on  Gunshot  Wounds.  The 
removal  of  foreign  bodies  from  the  internal  organs  and  the  large  cavi- 
ties of  the  body  is  discussed  in  the  Special  Surgery. 

When  the  treatment  of  the  wound  has  been  carried  out  in  the  man- 
ner described,  we  then  proceed,  in  the  case  of  large,  deep  wounds, 
to  provide  for  drainage  for  carrying  off  the  wound  secretion  (§  31). 
After  this,  in  proper  cases,  the  wound  is  closed  by  sutures  (§  33),  and 
an  antiseptic  dressing  is  applied  (§  §  44  -  49).  All  fresh  wounds 
which  are  not  infected  or  markedly  contused  are  suitable  for  sutur- 
ing. If  there  is  much  contusion  of  the  parts,  sutures  should  be  avoided, 
especially  on  the  skull,  where,  after  deficient  antisepsis,  a  retention  of 
the  secretion  from  the  wound  may  so  easily  become  dangerous  and 
lead  to  suppurative  phlebitis  with  secondary  fatal  meningitis.  If  the 
contusion  is  limited  simply  to  the  borders  of  the  wound  they  can  be 
excised  and  the  wound  then  closed  by  sutures.  In  all  cases  where  there 
is  doubt  about  the  propriety  of  suturing  the  wound,  it  is  preferable  to 
omit  it  entirely  or  to  suture  only  partially — for  example,  in  the  middle 
of  the  wound. 

Indications  for  Amputation  or  Disarticulation. — Amputation  or  disar- 
ticulation is  indicated 'in  fresh  cases  if  the  soft  parts  are  so  crushed  and 
disintegrated  that  either  the  repair  of  the  injury  is  impossible,  or,  if 
it  should  occur,  the  injured  limb  would  be  completely  useless.  "Ampu- 
tation is  also  indicated  in  cases  with  septic  cellulitis,  in  order  to  pre- 
vent death  from  sepsis.  When  amputation  has  to  be  performed  for 
fresh  lacerated  and  contused  wounds,  it  should  only  be  carried  out  in 
sound,  normal  tissues,  and  not  within  the  limits  of  the  contusion.  In 
general,  operations  should  be  as  conservative  as  possible,  especially  those 
upon  the  fingers.  If  all  the  fingers  have  to  be  removed  and  the  thumb 
only  can  be  saved,  this  should  be  done  in  every  case,  as  a  movable 
thumb  is  better  than  an  entire  artificial  hand.  In  the  tearing  away  of 
extremities  or  of  parts  of  them,  disarticulations,  amputations,  or  plastic 
operations  are  also  necessary  for  improving  the  stump  or  for  hastening 
recovery.  A  stump  of  bone  ])rojecting  from  the  soft  parts,  after  the 
latter  have  been  torn  from  the  phalanges  of  the  fingers,  must  always 
be  excised  or  disarticulated  by  the  saw,  chisel,  or  bone  forceps  at  a 
point  where  it  will  be  covered  by  soft  parts. 

Dressings,  packing  the  Wound,  etc. — The  protective  dressings  em- 
ployed for  superficial  cutaneous  wounds  and  for  all  small  wounds  con- 
sist of  English  sticking-plaster,  adhesive-plaster  gauze,  adhesive  plaster, 
strips  of  mull  with  collodion,  etc.  Superficial  abrasions  of  the  skin  are 
covered  with  iodoform  collodion  (1  to  10).     The  dressing  with  English 


§88.]  THE   TKEATiMKNT   OP    WOUNDS   OP   SOPT   PARTS.  477 

sticking-plaster  can  be  made  to  adhere  by  painting  it  over  with  collo- 
dion. Small  uninfected  wounds  closed  by  a  crust  of  blood,  etc.,  will 
heal  under  the  scab  without  a  dressing.  As  we  saw  in  §  §  44  -  4Y,  the 
number  of  antiseptic  dressings  is  very  great.  It  is  especially  ad- 
vantageous to  cover  the  wound  with  sterilised  gauze,  and  over  the 
latter  to  place  aseptic  cotton.  Dusting-powders,  like  iodoform,  derma- 
tolj  bismuth,  oxide  of  zinc,  etc.,  are  better  suited  for  unsutured  con- 
tused wounds.  Packing  with  ase})tic  gauze  or  iodoform  gauze  is  par- 
ticularly aj)plical)le  for  large  contused  and  lacei-ated  wounds,  with  or 
without  injury  to  bones,  joints,  etc.  After  removal  of  the  aseptic 
packing  the  wound  can  be  closed  by  secondary  sutures,  or  the  packing 
may  be  left  to  dry  and  form  a  firm  aseptic  scab  upon  the  wound  until 
it  falls  oif  of  its  own  accord.  In  suitable  cases — for  example,  in  ex- 
tensive contused  wounds — antiseptic  irrigation  (§  49)  should  be  em- 
ployed. Under  certain  conditions  it  is  an  excellent  plan  to  place  the 
patient  in  a  permanent  water-bath  (§  49). 

I  must  refer  the  reader  to  §  22  and  §  62  for  the  treatment  of  the 
general  condition  of  those  who  have  been  injured. 

Treatment  of  Secondary  Haemorrhage. — Any  secondary  haBmorrhages 
which  occur  during  the  healing  of  the  wound  are  to  be  arrested,  if  in 
an  extremity,  by  double  ligation  of  the  vessel  in  the  wound  Math  the 
assistance  of  Esmarch's  bandage.  The  ligation  of  the  principal  artery 
in  its  continuity  above  the  wound,  at  the  so-called  place  of  election,  is 
only  to  be  recommended  when  the  application  of  Esmarch's  bandage 
is  impossible  and  the  blood  wells  out  from  the  depths  of  the  wound  in 
such  amounts  that  there  is  danger  of  the  patient's  bleeding  to  death. 
In  such  critical  conditions  an  assistant  should  stop  the  hagmorrhage  by 
pressure  with  the  finger  in  the  wound  while  the  main  artery  is  rapidly 
secured  at  some  easily  accessible,  centrally  situated  point.  The  wound 
can  then  be  examined  more  leisurely  and  the  injured  vessel  tied  in  the 
wound  by  a  double  ligature.  The  leaving  in  place  of  artery  forceps,  a , 
firm  packing  of  the  wound  with  iodoform  gauze,  dressings  which  exert 
pressure,  digital  compression,  etc.  (§  §  28  and  29),  have  also  rendered 
excellent  service  in  cases  of  secondary  haemorrhage  from  deeply  lo- 
cated regions,  where  the  application  of  a  ligature  is  impossible  or 
difiicult. 

Suppuration — Burrowing  of  Pus. — During  the  healing  of  the  wound, 
especially  if  it  is  a  large  contused  or  suppurating  wound,  one  must 
always  guard  against  any  burrowing  of  pus.  If  spreading  inflamma- 
tion and  suppuration  are  already  present  in  the  wound  when  it  comes 
under  observation,  as  many  incisions  as  are  required  should  be  made, 
as  described  in  §  70  (cellulitis).     The  treatment  of  complications  of 


478    INJURIES  AND  SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

infected  wounds,  including  tlie  infectious-wound  diseases,  is  discussed 
in  §  §  62-82. 

Every  wound  until  it  has  cicatrised  should  be  treated  strictly  ac- 
cording to  antiseptic  rules ;  these  should  never  be  neglected,  especially 
during  a  change  of  dressings.  In  the  later  stages  of  repair  in  the 
wound,  especially  when  it  is  granulating,  ointment  dressings  are  to  be 
employed  (§  49).  The  final  skinning  over  of  a  granulating  wound  is 
often  hastened  by  the  occasional  use  of  the  nitrate  of  silver  stick.  By 
this  cauterisation  with  argent,  nitrat.,  we  make  the  shrinkage  of  the 
granulation  tissue  more  rapid  and  prevent  it  from  growing  too  luxuri- 
antly. We  cover  extensive  losses  of  substance  in  the  skin  with  trans- 
planted skin  (§  42),  or  by  plastic  operations  (§  41),  etc.  The  formation 
of  cicatricial  contractures  is  always,  as  far  as  possible,  to  be  prevented ; 
but  if  contractures  do  nevertheless  develop,  they  should  be  treated  in 
the  manner  described  on  pages  140,  299,  487,  and  in  §  119. 

For  finding  metallic  foreign  bodies  which  have  become  healed  up  iu  a 
wound  the  magnetic  needle  has  been  used  with  success.  By  its  deviations  it 
can  indicate,  for  example,  the  location  of  a  needle  which  has  become  healed 
up  in  the  wound  (Kocher,  etc.).  Also  for  finding  bullets  which  have  healed 
in,  the  magnetic  needle  can  be  used  with  advantage,  particularly  in  army 
surgery  (see  §  124).   ; 

§  89.  Treatment  of  the  Conditions  Following  Severe  Hsemorrhages — 
Blood  and  Common  Salt  Infusion. — If,  after  an  injury  to  large  arteries 
or  veins,  the  hiemorrhage  has  been  considerable,  the  general  weak  con- 
dition of  the  patient  very  often  demands,  after  arrest  of  the  bleeding, 
the  adoption  of  special  measures  which  must  be  carried  out  rapidly 
and  energetically.  In  the  milder  cases  of  swooning  after  loss  of  blood, 
the  head  should  be  placed  as  low  as  possible,  the  face  of  the  j^atient 
sprinkled  ^vith  water,  olfactory  stimulants,  such  as  ammonia,  adminis- 
tered, as  well  as  several  hypodermic  injections  of  ether ;  the  patient 
should  be  placed  as  soon  as  possible  under  warm  coverings  and  siir- 
rounded  by  hot  bottles,  sand-bags,  and  the  like,  besides  being  rubbed 
with  towels  and  stimulated  with  strong  wine,  cognac,  black  coffee,  etc. 
It  is  also  a  very  excellent  plan  to  supply  a  patient  who  has  lost  a  large 
amount  of  blood  with  great  quantities  of  heated  fluids ;  they  are  ab- 
sorbed from  the  gastro-intestinal  tract  more  rapidly  than  under  normal 
conditions,  and  are  a  direct  means  of  making  good  the  blood  deficiency. 
In  severe  cases  the  lowering  of  the  head  should  be  combined  with 
elevation  of  the  legs,  or,  better,  with  the  envelopment  of  the  legs  in 
an  elastic  bandage,  in  order  to  prevent  the  threatening  cerebral  anaemia 
and  to  drive  the  blood  out  of  the  extremities  towards  the  heart,  the 
lungs,  and  the  brain  (autotransfusion).     In^the  cases  of  verj-  extreme 


§8f).]  TREATMENT  OP  UiEMORRHAGES.  479 

aiuvniia  all  the  above-mentioned  remedies  will  be  of  no  avail  in  keep- 
ing the  patient  alive,  and  the  only  other  remedy  that  oilers  any  hope 
is  the  transfusion  or  infusion  of  blood  or  a  sterilised  physiological 
solution  of  sodium  eliloride. 

Transfusion  of  Blood  used  to  be  very  frequently  practised  for 
threatening  death  from  luemorrhage,  for  poisoning  by  illuminating  gas, 
carbonic  oxide,  carbonic  acid,  for  septica3mia,  and  for  various  internal 
diseases.  At  present  the  belief  in  the  capabilities  of  transfusion  has 
been  given  up,  and  the  operation  is  but  rarely  performed.  With  the 
increasing  knowledge  of  the  physiology  and  pathology  of  the  blood,  we 
have  found  that  the  earlier  views  and  presumptions  which  lay  at  the 
foundation  of  blood  transfusion  were  false.  I  fully  agree  with  Berg- 
mann  and  others  who,  reasoning  from  physiological  facts,  consider 
transfusion  not  onlv  a  useless,  but  also,  as  we  shall  see,  a  dansferous 
operation. 

Causes  of  Death  from  Haemorrhage. — The  cause  of  death  from 
haemorrhage  used  to  be  ascribed  to  the  loss  of  red  blood-corpuscles, 
and  hence  to  the  impoverishment  of  the  blood  in  haemoglobin,  or 
rather  in  oxygen.  But  now  we  know  that  death  from  hgeraorrhage 
is  dependent  upon  purely  mechanical  conditions.  It  is  caused  by  the 
insufficient  filling  of  the  vascular  system,  by  the  fall  of  the  arterial 
blood  pressure,  or,  in  other  words,  by  the  purely  mechanical  dispropor- 
tion between  the  capacity  of  the  vascular  system  and  the  amount  of 
its  contents.  For  this  reason  the  movement  of  the  contents  of  the 
vessels  ceases;  the  heart,  which  at  first  continues  to  beat,  is,  like  an 
empty  pump,  no  longer  able  to  raise  the  column  of  blood  and  drive  it 
onwards.  Hence  in  such  cases  the  indication  is  to  increase  the  con- 
tents of  the  vascular  system  by  infusion  of  some  liquid,  and  for  this 
purpose  the  blood  of  man  or  animals,  in  its  entirety,  or  defibrinated 
human  blood,  used  to  be  employed  ;  but  recently  the  infusion  of  an 
alkaline  seven-tenths  per-cent.  solution  of  common  salt  has  been  largely 
substituted  for  blood  transfusion  (Kronecker,  Sander,^  etc.). 

Infasion  of  a  Common  Salt  Solution. — As  a  matter  of  fact,  infusion  of 
common  salt  is  better  than  bloo<l  transfusion,  and  I  should  always  use 
it  in  cases  of  acute  anaemia.  The  recent  reports  of  Cavazzani,  Pors- 
tempski,  and  others,  which  favour  blood  transfusion,  do  not  influence 
my  views  in  the  least.  Landerer,  at  the  suggestion  of  C.  Ludwig  and 
Gaule,  has  proposed  the  addition  of  three  to  five  per  cent,  of  sugar  to 
the  alkaline  (0*7  per  cent.)  solution  of  common  salt.  The  advantage  of 
the  salt-sugar  solution  over  the  plain  salt  solution  consists,  according  to 
Ludwig,  in  the  fact  that  the  former  is  to  be  regarded  as  a  nutritive  solu- 
tion, and  that,  in  consequence  of  its  high  endosmotic  equivalent,  blood 


480    INJURIES  AND   SURGICAL   DISEASES  OP  THE   SOFT   PARTS. 

which  contains  sugar  takes  np  the  parenchymatous  fluids  more  ener- 
getically ;  moreover,  the  blood  pressure  rises  more  rapidly,  and  the  red 
blood-corpuscles  are  more  apt  to  remain  intact  than  when  a  pure  salt 
solution  is  employed.  It  is  simplest  to  infuse  the  salt  solution  subcu- 
taneously  (pages  483,  484.) 

Dangers  of  Blood  Transfusion. — That  the  transfusion  of  blood  in  any  form 
is  not  only  a  useless  but  also  a  dangerous  operation,  the  following  statements 
prove.  In  the  first  place,  we  know  from  the  experiments  made  by  Miiller 
and  Lesser,  under  the  guidance  of  C.  Ludwig,  that  all  the  red  blood-corpuscles 
injected  with  the  blood  are  destroyed  in  a  few  days.  The  corresponding 
hEemoglobinuria  which  accompanies  this  process  is  caused  by  the  disintegra- 
tion of  the  red  corpuscles,  or,  rather,  by  the  separation  of  the  haemoglobin 
from  the  stroma  of  the  red  corpuscles,  allowing  free  haemoglobin  to  circulate 
in  the  blood.  According  to  Sachsendahl,  the  dissolved  haemoglobin  is  the 
most  powerful  agent  for  bringing  about  a  rapid  destruction  of  the  colourless 
blood-corpuscles  and  a  very  sudden  and  marked  accumulation  of  the  fibrin 
ferment  in  the  circulating  blood,  so  that  death  may  occur  from  ferment 
intoxication. 

Magendie  uttered  a  warning  against  the  use  of  defibrinated  blood,  because 
its  injection  was  followed  by  very  definite  disorders,  such  as  rapid  respira- 
tion, diarrhoea,  bloody  transudations  into  the  peritonaeum,  the  pleura  and 
pericardium,  and  even  by  death.  The  interesting  investigations  of  Armin 
Kohler  show  the  possibility  of  ferment  intoxication  after  blood  transfusion. 
He  demonstrated  that  blood  taken  from  another  species,  as  well  as  blood 
from  the  same  species,  had  a  poisonous  action.  If  only  ten  to  twelve  cubic 
centimetres  of  blood  were  drawn  from  the  carotid  of  a  strong  rabbit,  allowed 
to  coagulate,  and  the  blood  coagulum  then  chopped  up,  pressed  between 
pieces  of  linen,  filtered,  and  of  this  defibrinated  blood  only  five  to  six  cubic 
centimetres  were  injected  slowly  into  the  internal  jugular  vein  of  the  same 
animal,  it  usually  died  during  the  injection,  from  extensive  coagulation  in 
the  right  heart  and  in  all  the  branches  of  the  pulmonary  artery  in  both 
lungs.  These  facts  are  explainable  upon  Schmidt's  theory  of  coagulation. 
The  flbrino-plastic  substance,  and  particularly  the  fibrin  ferment,  are  found 
free  in  blood  defibrinated  in  the  above  manner,  and  being  carried  in  this 
state  into  the  circulating  blood  they  excite  within  the  blood  channels  exten- 
sive thromboses.  The  animal  dies  in  consequence  of  the  ferment  intoxica- 
tion. Pepsin  and  pancreatin  have  an  effect  analogous  to  the  blood  ferment 
(Bergmann,  Angerer).  Blood  defibrinated  by  beating  or  shaking,  according 
to  the  old  method  of  blood  transfusion,  is  not  by  any  means  as  rich  in  the 
fi.brino-plastic  substance  and  in  the  fibrin  ferment  as  blood  which  has  been 
pressed  in  the  manner  just  described,  but  it  is  only  a  difference  in  quantity; 
consequently  Kohler  is  right  in  considering  blood  which  has  been  defibrin- 
ated by  whipping  not  so  harmless  as  has  been  hitherto  supposed.  As  regards 
the  histocym  isolated  from  the  blood  by  Schmiedeberg,  see  page  307. 

Transftision  of  Animal  Blood,— In  the  transfusion  of  blood  taken  from 
another  species  of  animal  still  other  conditions  come  into  consideration. 
Partly  as  a  result  of  chemical  action  and  partly  as  a  result  of  the  above- 


g80.]  TREATMENT   OF    ILEMORRHAGES.  481 

meutioucd  disiiitcfjration  of  the  red  blood-corpuscles,  the  blood  of  a  sheep, 
for  example,  is  a  fatal  poison  for  a  dog  if  injected  in  sufficient  amount  into 
the  vascular  system  of  the  latter  ;  and  again,  a  dog's  blood  is  just  as  poison- 
ous for  a  sheep.  After  the  direct  introduction  of  lamb's  or  dog's  blood  into 
the  veins  of  a  man,  dangerous  symptoms  had  been  observed  more  than  two 
hundred  years  ago,  and  yet  about  fourteen  years  ago  an  attempt  was  made  to 
reintroduce  the  transfusion  into  man  of  lamb's  blood.  Chills,  fever,  haemo- 
globinuria,  as  a  result  of  the  disintegration  of  the  red  corpuscles  in  the  circu- 
lating blood,  and  not  infrequently  death,  were  the  consequences.  Panum,  Lan- 
dois  and  Ponfick  have  proved  by  numerous  experiments  the  dangers  of  the 
transfusion  of  animal  blood  into  man,  and,  in  fact,  the  danger  of  transfusion 
of  blood  in  any  form  which  has  been  taken  from  another  species.  We  shall 
now  always  be  on  our  guard  against  a  return  to  the  transfusion  of  animal  blood. 

Direct  Blood  Transfusion.— It  would  be  most  advantageous  if  the  blood  in 
its  entirety  could  be  conducted  from  the  artery  of  a  man  into  the  vein  of  the 
receiver.  But  all  kinds  of  difficulties  stand  in  the  way  of  employing  this 
direct  transfusion.  It  is  not  so  easy  to  find  any  one  who  will  give  blood 
directly  from  an  artery  as  one  who  will  give  it  from  a  vein.  Then,  the  pos- 
sibility of  the  blood  coagulating  in  the  conducting  tube  must  be  taken  into 
consideration.  Furthermore,  it  is  always  questionable  whether  the  corpus- 
cles retain  their  vitality  in  the  blood  of  the  receiver. 

Wright  and  Hertig  have  recommended  decalcified  blood  for  transfusion, 
as  Arthus  and  Pages  found  that  it  did  not  coagulate  (see  page  293). 

As  a  substitute  for  the  introduction  of  blood  into  the  vascular  system, 
Ponfick  has  recommended  intra-peritoneal  transfusion— i.  e.,  the  infu.sion  of 
defibrinated  blood  into  the  peritoneal  cavity.  The  clinical  and  experimental 
investigations  of  Angerer,  Edelberg  and  others  have  taught  that  this  method 
should  be  condemned. 

Ziemssen  has  employed  with  advantage  in  chi'onic  anaemia  the  subcu- 
taneous injection  of  defibrinated  blood  at  a  temi^erature  of  37°  to  40°  C.  into 
the  subcutaneous  tissue  of  the  thigh,  using,  for  example,  three  hundred  and 
fifty  grains  in  about  fourteen  injections.  For  acute  anaemia  Ziemssen  and 
others  recoinmend  the  subcutaneous  injection  of  a  sterilised,  physiological, 
seven-tenths  per-cent.  solution  of  common  salt. 

Indications  for  Infusion  of  Blood  and  Sodinm  Chloride.— The  indications 
for  undertaking  blood  or  common-salt  infusion  are  most  frequently  a  high 
grade  of  anaemia  after  loss  of  blood,  and  poisoning  by,  for  example,  carbonic- 
oxide  gas  and  illuminating  gas.  in  which  common  salt  infusion  has  also 
repeatedly  proved  efficacious.  The  operation  is  no  longer  employed  for  sep- 
ticaemia or  chronic  diseases  of  the  blood  (chlorosis,  leucocythaemia,  pernicious 
anaemia,  etc.).  nor  for  chronic  marasmus. 

General  Technique  of  Blood  and  Common  Salt  Infusion.— The  transfusion 
is  carried  out  without  an  anaesthetic,  in  order  that  the  behaviour  of  the  patient 
during  the  infusion  can  be  more  accui'ately  observed.  The  operation  is  not 
painful,  and  very  often  the  patients  are  vmconscious.  During  the  transfu- 
sion of  blood  a  greater  or  less  amount  of  dyspnoea  and  cyanosis  is  usually 
observed,  and  both  manifestations  not  infrequently  become  so  pronounced 
that  the  operation  has  to  be  suspended.  Furthermore,  li  fainting-fits  super- 
vene, the  infusion  should  be  immediately  stopped. 
31 


482    INJURIES   AND  SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

Technique  of  the  Transfusion  of  Venous  Blood.— In  venous  transfusion 
with  defibrinated  liuman  blood,  about  two  hundred  to  four  hundred  grammes 
of  blood  are  drawn  from  a  vein  of  a  strong  man  into  a  carefully  disinfected 
glass  vessel.  The  blood  is  heated  on  a  water  bath  to  about  39°  to  40°  C. 
(102"2°  to  104°  F.),  defibrinated  by  whipping  with  a  clean  glass  rod,  then  fil- 
tered through  clean  linen  in  a  glass  funnel  into  another  glass  vessel  kept  at 
about  39°  to  40°  C.  (102-2°  to  104°  F.)  over  a  water  bath.  While  an  assistant 
attends  to  the  defibrination  and  filtration  of  the  blood,  a  large  cutaneous  vein 
— usually  at  the  elbow — is  picked  out.  The  finding  of  the  vein  can  be  facili- 
tated by  causing  it  to  become  distended  with  a  phlebotomy  bandage  wound 
ai'ound  the  (upper)  arm.  After  exposing  the  vein  and  isolating  some  2 '8 
centimetres  of  its  extent,  two  catgut  ligatures  are  passed  under  it,  and  the 
vein  is  gently  lifted  with  the  peripheral  ligature  and  opened  by  scissors.  A 
disinfected  glass  cannula  is  pushed  into  the  opened  vein  in  the  direction  of 
the  blood  current  and  secured  by  the  other  ligature.  The  bleeding  from  the 
vein  is  checked  simply  by  lifting  the  vein  by  the  peripheral  ligature,  or  the 
latter  may  be  knotted.  The  glass  cannula  is  filled  with  blood,  and  then  the 
warm  defibrinated  blood  is  injected  by  a  glass  syringe,  which  is  not  too  large, 
or  a  glass  jar  is  used  with  a  rubber  tube  like  an  irrigator.  About  two  hun- 
dred to  three  hundred  grammes  are  injected  slowly  ;  Hueteir  recommends  the 
injection  of  four  hundred  grammes  or  more.  The' entrance  of  air  into  the 
vein  and  the  formation  of  coagula  are  especially  to  be  avoided.  The  strict- 
est asepsis  as  regards  the  giver  and  receiver  of  the  blood  must  always  be 
observed. 

Technique  of  Arterial  Blood  Transfusion.— In  arterial  transfusion  (Grafe, 
Hueter)  the  radial  or  ulnar  artery  is  exposed  and  sufficiently  isolated  above 
the  wrist  joint.  Three  catgut  ligatures  are  then  pushed  under  the  artery. 
The  centrally  located  ligature  is  knotted  and  occludes  the  artery,  while  a 
simple  knot  or  sling  is  made  with  the  peripheral  ligature,  or  the  vessel  is 
closed  temporarily  with  a  small  artery  clamp.  The  artery  is  then  opened 
with  scissors  between  the  two  ligatures  or  on  the  proximal  side  of  the  periph- 
erally placed  artery  clamp,  a  glass  tube  is  pushed  into  the  hole  in  the  artery 
towards  the  peripheiy  and  firmly  secured  with  the  third  ligature.  The  fur- 
ther course  of  the  operation  is  the  same  as  above. 

After  the  termination  of  the  transfusion  the  artery  and  vein  are  tied  cen- 
trally and  peripherally,  the  intervening  portion  used  for  the  infusion  is  ex- 
tirpated, and  the  glass  cannula  removed.  Hueter  claims  that  the  advantage 
of  arterial  transfusion  lies  in  the  fact  that  the  blood  is  first  driven  into  the 
capillaries,  and  the  latter  act  as  a  filter  for  any  clot  that  may  be  injected  ; 
there  is,  moreover,  no  danger  of  the  entrance  of  air. 

Technique  of  Direct  Blood  Transfusion.— In  the  direct  conduction  of  blood 
from  an  artery  into  a  vein  the  above  rules  are  followed — i.  e.,  a  glass  cannula 
is  tied  into  the  vein  of  the  receiver  and  one  into  the  artery  of  the  giver  of 
the  blood,  and  both  are  connected  by  a  rigorously  disinfected  rubber  tube  in 
which  a  glass  tube  is  sometimes  interposed  to  control  any  coagulation. 

Technique  of  Sodium-Chloride  Infusion.— In  the  sodium-chloride  infusion, 
which  should  be  undertaken  as  soon  as  possible  after  the  hgemorrhage  and 
with  the  strictest  asepsis,  a  sterilised  seven-tenths-per-cent.  solvition  of  com- 
mon salt  warmed  to  about  39°  C.  (102'2°  F.)  is  used,  which  is  rendered  alka- 


^  B!).] 


TREATMENT   OK    ILKMOIIRIIAGES. 


483 


lino  by  the  addition  of  sodium  hydroxide  or  potassium  carbonate.  Szuman 
recommends  aq.  destil.  1,000,  sod.  chloral.  (>"0,  sod.  carb.  10.  For  one  to  one 
and  a  half  litres  of  a  seven-tentli.s-per-cent.  solution  of  common  salt  about 
three  drops  of  sodium  liydraleaic  suflicient.  According  to  Krouecker,  the 
solution  of  salt  should  be  073  per  cent,  and  neutral — alkaline  liquids  may 
prove  dangerous— or  the  above-mentioned  salt-sugar  solution  of  Ludwig'.s 
may  be  used.  For  infusion,  a  gla.ss  funnel  is  employed,  or  a  glass  flask  with 
a  tube  at  the  bottom  connecting  it  with  a  rubber  tube  and  a  glass  cannula. 
The  infusion  should  take  place  under  no  higher  pressure  than  exists  in  the 
large  veins.  Jacobson  states  that  this  is  represented  at  the  most  by  one  centi- 
metre of  mercury  or  thirteen 
centimetres  of  the  sodium-chlo- 
ride solution — i  e.,  the  infusioti 
flask  should  not  be  held  higher 
than  013  to  0*25  millimetre 
above  the  opening  in  the  vein. 
During  the  infusion  the  body, 
especially  the  abdominal  visce- 
ra, should  be  vigorously  mas- 
saged. Five  hundred  cubic  cen- 
timetres at  the  least  are  injected, 
and  in  severe  cases  of  haemor- 
rhage about  one  thousand  to 
fifteen  hundred  cubic  centime- 
tres. The  infusion  should  not 
be  carried  on  too  rapidly,  about 
sixty  to  ninety  cubic  centime- 
tres being  injected  in  a  minute. 
The  success  of  sodium-chloride 
infusion  has  so  far  been  very 
encouraging.  The  venous  salt 
infusion,  according  to  the  ex- 
perience we  have  had  with  it, 
should  be  preferred  to  the  arte- 
rial. The  arterial  salt  infusion 
has  also  been  made  into  the 
central  end  of  an  artery,  the 
radial,  for  example ;  but  this 
method  has  no  advantage  over 
the  venous  infusion. 

Kiimmel  likewise  warns 
against  infusing  salt  solution 
into  an  artery.  After  the  infu- 
sion with  a  glass  syringe  of 
about  five  hundred  grammes  of 
a  six-tenths-per-cent.  alkaline  salt  solution  into  the  radial  artery,  gangrene  of 
the  skin  follow^ed,  rendering  it  necessai'y  to  amputate  the  forearm  between 
the  lower  and  middle  thirds. 

Subcutaneous  Salt  Infusion.— According  to  my  own  experience,  the  subcu- 


Fkt.  308. — Apparatus  for  the  tran.sfu.sion  of  a  saline 
solution,  oonsLstin)?  of  a  glass  vessel  with  a  rubber 
stopper  having  three  lioTes;  a  thermometer  (^77/), 
a  rubber  tube  with  an  interposed  glass  tube,  u 
stop-cock  (Q),  and  a  hollow  needle. 


484    INJURIES  AND  SURGICAL    DISEASES  OF   THE   SOFT   PARTS. 

taneous  infusion  of  a  sterilised  seven-teuths-per-cent.  solution  of  common  salt 
is  exceedingly  good.  The  investigations  of  Ziemssen,  Samuel,  etc.,  have  dem- 
onstrated that  the  system,  even  when  the  activity  of  the  heart  is  impaired, 
is  still  ahle  to  take  np  into  its  circulation  great  quantities  of  salt  solution  in- 
jected subcutaneously.  It  is  injected  through  a  hollow  needle  into  various 
parts  of  the  body,  particularly  beneath  the  skin  over  the  abdomen,  by  means 
of  some  apparatus  like  that  of  Sahli's,  illustrated  in  Fig.  308;  five  hundred 
to  one  thousand  cubic  centimetres,  warmed  to  39°  C  (102 "2°  F.),  are  injected 
during  five  to  ten  to  fifteen  to  twenty  to  thirty  minutes,  according  to  the 
nature  of  the  case,  and  absorption  is  hastened  by  gentle  rubbing  (massage). 
I  have  seen  remarkable  results  in  acute  anaemia,  and  in  collapse  after  pro- 
longed operations  on  weak  individuals.  In  proper  cases  several  litres  of  salt 
solution  can  be  injected  subcutaneously  on  several  different  days.  In  one 
patient  wdth  chronic  mercurial  poisoning,  Sahli  washed  out  the  body,  as  it 
were,  with  twenty -one  litres  of  salt  solution  in  eight  sittings;  each  time  two 
and  a  half  to  four  litres  were  infused  subcutaneously.  However,  a  therapeu- 
tic success  was  not  obtained,  since  the  mercury  could  not  be  demonstrated 
in  the  urine.* 

Infusion  of  Warm  Water.— In  one  case  Coates  made  a  successful  injection 
of  six  hundred  and  fifty  grammes  of  pure  warm  water  into  the  cephalic  vein. 

Milk  Infusion. — At  the  end  of  the  eighteenth  century  Muralto  recom- 
mended the  injection  of  milk  instead  of  blood.  American  physicians  in  par- 
ticular are  said  to  have  used  milk  infusions  into  the  veins  with  success.  But 
Landois  and  others  have  shown  by  animal  experimentation  that  the  proce- 
dure is  to  be  condemned  as  directly  dangerous  to  life;  its  results  are  marked 
disturbances  of  circulation,  coagulations,  and  emboli.  Vigezzi  has  recently 
tested  experimentally  the  infusion  of  milk  into  veins,  and  he  states  that 
acidified  milk  brings  about  the  above-mentioned  dangerous  manifestations, 
but  that  milk  mixed  with  an  alkaline  solution  is  entii'ely  harmless.    ; 

§  90.  Burns. — Burns  originate  in  a  great  many  different  ways — e.  g., 
by  direct  contact  of  the  affected  portion  of  the  body  with  a  flame,  or 
by  the  explosion  of  powder,  illuminating  gas,  "  fire-damp,"  etc.  Fire- 
damp occurs  in  coal  mines  in  particular,  and  causes  an  explosion  if 
mixed  with  a  double  volume  of  oxygen  or  a  tenfold  volume  of  air 
and  brought  in  contact  with  a  flame.  Burns  are  very  often  due  to  the 
action  of  hot  gases,  steam,  liquids,  hot  solid  bodies,  such  as  metals,  etc. 
In  this  class  of  cases  belong  the  injuries  caused  by  caustic  substances 
such  as  concentrated  acids  (sulphuric  acid,  nitric  acid,  etc.),  and  by 
caustic  alkalies.  Comparatively  mild  burns  of  the  skin  are  caused  by 
the  sun's  I'ays. 

Symptoms  and  Course  of  Burns. — The  clinical  course  of  a  burn  de- 
pends upon  its  intensity  and  extent.  The  intensity  of  the  burn  is  con- 
ditional upon  the  degree  of  the  heat  and  the  duration  of  its  action. 
The  purely  local  manifestations  may  occur  in  three  different  degrees  of 

*  Sahli,  Sainnil.  klin.  Vortr.,  N.  F.,  No.  11. 


§  '■'<>• 


BURNS. 


48i 


severity:  First  degree,  huperoimia  j  second  degree,  hh^h  formation  j 
third  degree,  i'sc/iarforjiKdlon. 

Burns  of  the  First  Degree. — The  Jird  degree  is  characterised  by  a 
painful  reihiess  and  slight  swelling  of  the  skin — i.  e.,  by  a  dilatation 
of  the  capillaries,  with  a  slight  exudation  of  serum,  as  in  erythema,  or 
in  a  mild  inflammation.  In  the  mildest  cases  the  redness  disappears 
in  a  short  time  and  nothing  follows.  \Gyy  frequently  the  horny  laj-er 
of  epidermis  is  cast  off  in  the  form  of  small  scales  or  patches.  In  the 
Becond  degree  of  burn  we  observe,  in  addition  to  the  manifestations  of 
the  iirst  degree,  the  development  of  small  and  large  hlehs^  which  are 
tilled  with  a  watery,  transparent,  or  slightly  yellow  serum,  and  here 
and  there  with  serum  mixed  with  blood.  These  blebs  either  develop 
immediately  or  in  the  course  of  the  next  few  hours  after  the  reception 
of  the  burn.  The  blebs  are  usually  located  in  the  epidermis,  and  their 
contents  raise  the  horny  layer  from  the  underlying  layer  of  the  rete 
Malpighii.  The  rapid  development  of  the  blebs  in  a  burn  has  not  yet 
been  clearly  explained.  In  burns  of  this  second  degree  the  swelling 
and  pain  are  usually  very  considerable,  especially  at  those  points  where 
there  is  much  tension,  or  when  the  blebs  are  removed  and  the  very 
sensitive  reddened  corium  is  exposed  to  the  air.  If  the  blebs  break  or 
are  artificially  opened,  the  epidermis  beneath  the  portion  that  has  been 
lifted  up  forms  a  new  horny  laj'er 
within  three  to  six  to  eight  days,  and 
from  this  the  shreds  of  the  old  horny 
layer  can  be  easily  removed.  If  the 
true  cutis  is  exposed,  or  if  the  latter 
is  involved  in  the  burn,  suppuration 
often  ensues ;  but  it  can  be  entirely 
prevented  by  antiseptic  dressings,  after 
previously  carefully  disinfecting  the 
parts.  These  latter  cases  form  the  tran- 
sition to  burns  of  the  third  degree^  in 
which,  as  a  result  of  the  action  of  very 
severe  heat,  an  eschar  is  formed.  The 
appearance  of  the  eschar  varies  greatly, 
being  ashy  grey,  brown,  yellow  or  black 
in  colour,  and  either  moist  or  dr}-. 
The  separation  of  tlie  eschar  is  brougKt  about  by  the  ensuing  suppura- 
tion, which  can  be  limited  or  prevented  by  antiseptic  treatment.  In 
burns  of  the  third  degree  the  difference  between  individual  cases  is 
very  great,  and  they  include  burns  varying  from  a  partial  destruction 
of  the  cutis  to  a  complete  carbonisation  of  an  entire  extremity.     Hence 


-:«^^ 


t 


P%' 


S^, 


^SW^^' 


Fig.  309. — Cicatrix  resultiug  from  a  burn 
with  boiling  water,  observed  in  a 
boy  five  years  old. 


486    INJURIES   AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

it  follows  that  the  division  of  burns  into  three  degrees  is  somewliat 
illusory,  and  there  have  been  surgeons  who  have  distinguished  seven 
to  ten  degrees  of  burns.  But  the  division  of  burns  into  three  degrees 
is,  on  the  whole,  the  best. 

The  casting  off  of  the  burned  tissue  occasionally  takes  a  very  long 
time,  especially  when  bones  are  involved.  When  the  eschar  has  been 
removed,  and  a  correspondingly  large  granulating  wound  surface  lias 
taken  its  place,  the  skin  gradually  forms  over  it,  as  described  in  §  61. 
A  very  extensive  destruction  of  skin  is  often  observed  after  burns, 
causing  great  obstacles  to  repair.  The  cicatrix  not  infrequently  gives 
rise  to  various  disturbances  of  function  and  to  deformities,  amongst 
which  mention  should  be  made  of  ectropion  of  the  eyelids,  adhesion  of 
the  chin  to  the  chest,  contractures  of  joints  in  the  extremities,  etc. 
(P"'ig.  309).  These  cicatricial  contractures  are  best  prevented  by  the 
transplantation  of  large,  fresh  cutaneous  flaps  with  pedicles,  or  by  skin 
grafting. 

Constitutional  Symptoms  after  a  Burn. — The  constitutional  symp- 
toms observed  after  the  reception  of  a  burn  depend  in  the  first  place 
upon  the  extent  of  the  burn.  It  is  generally  accepted  that  when  more  ^/^ 
than  half  the  surface  of  the  body  is  burned  even  to  a  slight  extent  death  " 
is  certain  to  follow  ;  in  many  cases  death  ensues  when  the  burn  involves 
only  a  third  of  the  body.  The  carbonisation  of  an  extremity  is,  in 
general,  better  borne  than  an  extensive  slight  burn  of  the  surface  of  tlie 
body.  After  extensive  burns  death  ensues  either  immediately  after  the 
injury  or  in  the  course  of  the  first  or  second  day,  or  after  several 
days  or  weeks — i.  e.,  either  in  the  stage  of  inflammatory  reaction,  or 
in  that  of  suppuration  and  exhaustion. 

Immediately  after  the  reception  of  an  extensive  burn  the  patient  is 
usually  in  a  state  of  great  excitement,  he  complains  of  severe  pain  in  the 
injured  part,  and  often  cries  and  screams.  The  mind  is  at  first  entirely 
clear.  In  the  cases  running  a  rapidly  fatal  course  the  patients  are 
very  restless  and  toss  about  in  l)ed ;  delirium  and  cramps  come  on,  the 
thready  pulse  is  extremely  rapid,  the  temperature  of  the  body  is  below 
normal — sometimes  as  much  as  3°  to  5°  F. — the  respiration  is  superficial 
and  rapid,  the  extremities  are  cool,  and  death  usually  follows  with  in- 
creasing symptoms  of  collapse  and  coma.  The  lowering  of  the  tempera- 
ture occurring,  as  a  rule,  in  extensive  burns  of  the  skin  is  due  to  the 
abnormally  increased  radiation  of  heat  from  the  dilated  vessels  in  the 
affected  parts  which  have  been  robbed  of  their  protecting  epidermic 
covering.  In  a  number  of  cases  of  burns  very  pronounced  excitement 
is  present  until  shortly  before  death,  while  other  patients  lie  quietly  in 
a  state  of  apathy.     There  is  often  vomiting  and   great  thirst.     The 


g!»O.J  BURNS.  487 

urine,  in  the  majority  of  instances,  is  very  scanty,  and  occasionally 
there  may  be  more  or  less  complete  anuria,  and  not  infrequently 
haMnog-luhinuria.  The  latter  is  a  result  of  the  destruction  of  the  red 
blood-corpuscles  which  were  in  the  vessels  of  the  affected  part  at  the 
time  of  the  burning.  If  the  patient  survives  the  first  two  days  much 
has  been  gained,  but  after  the  lapse  of  five  to  six  days,  in  the  stage  of 
the  infiannnatory  reaction,  the  above-described  group  of  symjitoms 
may  suddenly  make  their  appearance  and  cause  death  within  a  few 
hours.  In  the  later  stages  the  cause  of  death  is  due  essentially,  as  we 
have  said,  to  the  increasing  exhaustion  ;  a  violent  diarrhea  begins, 
with  now  and  then  the  formation  of  ulcers  in  the  duodeiium,  usually 
in  the  neighbourhood  of  the  pylorus. 

Causes  of  Death  after  Extensive  Burns.— How  is  the  death  which  quickly 
ensues  after  extensive  burns  to  be  explained  ?  The  opinions  of  various  au- 
thorities differ  greatly  upon  this  subject,  and  as  yet  no  generally  satisfac- 
toi'v  explanation  lias  been  advanced.  According  to  Wertheim,  Ponfick,  and 
others,  the  above-mentioned  destruction  of  the  red  blood-corpuscles  is  the 
main  cause  of  death.  The  marked  diminution  in  the  number  of  red  blood- 
corpuscles  which  are  necessary  for  respiration  and  for  metabolism,  produces, 
according  to  this  view,  death,  with  symptoms  similar  to  those  in  carbonic- 
acid-gas  poisoning ;  or  the  sudden  death  of  the  red  blood-corpuscles  has  in 
itself  a  deleterious  effect.  In  consequence  of  the  destruction  of  the  red  cells, 
the  haemoglobin  is  dissolved  in  the  blood,  and  this,  as  we  know,  is  also  a 
means  of  rajjidly  destroying  the  white  blood-corpuscles,  and  of  favouring  the 
development  of  the  fibrin  ferment,  and  of  extensive  coagula  in  the  vessels. 
As  a  matter  of  fact,  extensive  thi'ombi,  originating  intra  vitam,  are  found  in 
the  vessels  of  all  the  different  organs;  this  has  been  recently  demonstrated 
in  man  and  animals  by  Silbermann  and  Welti.  Furthermore,  larger  or 
smaller  amounts  of  haemoglobin  are  frequently  found  in  the  kidneys,  it  be- 
ing most  plentiful  in  the  straight  uriniferous  tubules,  though  occurring  also 
in  the  convoluted  tubules  and  within  Bowman's  ca])sule.  From  the  presence 
of  haemoglobin  such  kidneys  have  a  dark,  brownish-red  colour,  which  used 
to  be  erroneously  ascribed  to  excessive  hypera^mia.  In  addition,  the  kidneys 
are  more  or  less  hyperaemic,  and,  like  the  stomach  and  liver,  full  of  necrotic 
foci.  These  necroses  become  more  extensive  with  the  prolongation  of  life 
after  the  reception  of  the  burn  (Welti).  The  diminished  excretion  of  urine 
is  explained  by  the  changes  in  the  kidnej'S.  Eeasoning  from  his  experi- 
ments and  observations,  Sonnenburg  has  come  to  the  conclusion  that  death 
after  extensive  burns  is  caused  either  by  the  overheating  of  the  blood  with 
subsequent  cardiac  paralysis  (in  such  cases  it  immediately  follows  the  in- 
jury), or  that  the  characteristic  manifestations  of  collapse  are  to  be  regarded 
as  the  effect  of  an  excessive  irritation  of  the  nervous  system,  which  has,  as  its 
reflex  result,  a  lowering  of  the  tone  of  the  vessels.  The  hyperasmia  and 
ecchymoses  of  the  internal  organs  so  frequently  found  in  autopsies  upon 
people  who  have  been  burned,  Sonnenburg  ascribes  to  the  diminution  of  the 
vascular  tone  which  has  been  brought  alout  reflexly. 


488    INJURIES   AND   SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

According  to  Salvioli,  the  cause  of  death  from  burns  is  to  be  sought  for 
mainly  in  the  formation  of  numerous  thrombi  and  emboli  made  up  of  blood- 
plaques.  In  consequence  of  these  blood-plaque  thronibi,  and  in  consequence 
of  the  increased  adhesiveness  of  the  blood-corpuscles,  the  circulation  finally 
comes  to  a  complete  stand-still.  After  animals  have  been,  as  far  as  possi- 
ble, deprived  of  the  blood-plaques  by  venesection  and  injection  of  defibri- 
nated  blood,  they  endure  severe  burns  much  better,  for  the  reason  that  the 
above-mentioned  thrombi  do  not  develop. 

According  to  Lustgarten,  death  from  burning  is  due  to  ptomaine  poison- 
ing. The  intoxication  Ls  caused  by  the  metabolic  products  of  the  organisms 
of  decomposition  which,  lying  in  the  depths  of  the  cutaneous  follicles,  have 
escaped  the  effects  of  the  bum. 

The  other  theories  about  the  causes  of  death  after  extensive  burns  lack  a 
foundation  in  fact,  and  have  found  but  few  adherents.  I  will  mention  only 
the  stoppage  of  the  activity  of  the  skin  as  a  result  of  extensive  hums,  the 
accumulation  in  the  blood  of  certain  poisonous  substances  like  ammonia 
(ammoncemia),  and  the  loss  of  blood  serum  with  the  consequent  thickening 
of  the  blood. 

Recently  Catiano  has  again  adopted  the  theory  that  death  after  extensive 
burns  is  caused  by  noxious  chemical  substances.  He  has  raised  the  question 
whether,  in  extensive  burns,  a  substance  found  mostly  in  the  skin  is  not 
changed,  by  being  rapidly  heated,  into  a  poison,  the  absorption  of  which  gives 
rise  to  the  disturbances  in  question.  The  sweat  of  the  skin  has  an  acid  re- 
action from  formic  acid  (CH2O2).  If  this  Is  gradually  neutralised  on  the 
skin  by  ammonium  hydroxide  there  forms  the  very  easily  soluljle  formate  of 
ammonium.  If  this  salt  is  rapidly  heated  it  loses  water  and  changes  into 
hydrocyanic  acid.  The  symptoms  of  hydrocyanic-acid  poisoning  are  said 
to  be  in  every  respect  similar  to  those  following  burns. 

The  causes  of  death  in  the  later  stages  of  the  inflammatory  reaction,  as 
well  as  during  the  period  of  suppuration  and  exhaustion,  var\'  greatly  in 
their  nature.  The  intensity  of  the  burn  and  the  subsequent  supi>uration,  the 
fever,  and  the  individual  peculiarities  of  the  injured  pej^on  are  here  the  most 
important  factors.  Amongst  the  inflammations  of  the  internal  organs  the 
most  frequently  observed  are  inflammations  of  the  intestines,  the  kidneys, 
the  lungs,  the  pleurae,  and  the  meninges;  they  are  rarely  caused  by  the  action 
of  the  heat  during  the  reception  of  the  burn,  but  are  much  more  frequently 
a  result  of  the  gradual  alteration  in  the  blood  that  occurs  after  the  burn. 

Duodenitis  after  Burns. — The  origin  of  the  duodenal  idceration  after 
burns,  mentioned  on  page  487,  has  not  as  yet  been  cleai'ly  explained.  Catiano 
believes  that  the  duodenal  ulcers  and  the  intestinal  catarrh  originate  from 
the  destruction  of  the  e]Hthelial  layer  and  the  action  of  the  intestinal  juice  upon 
the  exposed  parts.  The  epithelial  destruction  is  said  to  be  produced  by  for- 
mate of  ammonium,  which  is  formed  by  the  decomposition  of  the  hydrocyanic 
acid  in  the  organism.  Hunter  also  is  of  the  opinion,  rea.souiug  from  his 
experiments  upon  dogs  with  toluylendiamin,  that  analogously  to  the  way 
this  substance  acts,  certain  similar  products  of  decomposition  in  the  tissues 
are  produced  in  cases  of  burns  which  are  excreted  in  the  bile  and  are  capable 
of  exciting  inflammation  and  ulceration  in  the  duodenal  mucous  membrane. 

Since  the  time  that  we  have  boen  able,   with  the  help  of  the  modern 


g !)().]  BURNS.  489 

method  of  treating  wounds,  to  control  suppuration  and  its  accompanying 
fever  and  prostration,  as  well  as  the  accidental-wound  diseases,  cases  of  death 
from  suppuration  and  other  wound  infections  after  burns  have  become  less 
common. 

Prognosis  of  Burns. — The  prognosis  of  burns  may  be  inferred  from 
wliat  has  been  said.  The  more  extensive  a  burn  is,  so  much  the  more 
unfavourable  is  tlie  prognosis,  qtwad  vitam.  In  addition,  tlie  location 
and'depth  of  the  burn,  as  well  as^the  age  and  constitution  of  the  pa- 
tient, play  an  important  part.  Quoad  functionem,  "burns  of  the  third 
degree,  involving  the  entire  thickness  of  the  cutis,  are  alone  to  be 
feared,  on  account  of  the  cicatricial  contractures  which  may  result. 
Contractures  of  the  joints,  abnormal  adhesions,  such  as  adhesion  of  the 
chin  to  the  neck,  adhesions  between  the  two  jaws,  contractures  of  the 
eyelids,  etc..  result  in  this  way. 

Treatment  of  Burns. — Leaving  for  the  present  the  treatment  of  exten- 
sive burns  endangering  life  out  of  consideration,  the  local  treatment  of 
burns  of  the  first  degree  is  mainly  directed  towards  the  alleviation  of 
the  pain.  This  is  best  accomplished  by  the  local  use  of  cold  in  the  form 
of  ice  bags  and  ice  compresses ;  \^  the  use  of  liquor  plumbi  subacetatis 
dilutus  with  ice  Hjv  cold  baths  ;  by  painting  with  flexible  collodium,  un- 
guentum  cerussse  or  unguentum  lithargyri  Ilebrse  (unguentum  diachy- 
lon) after  dusting^n  starch,  or  starch  with  oxide  of  zinc,  dermatol,  etc., 
-with  or  without  an  occlusive  dressing  of  cotton  wool.  Protective  dress- 
ings, according  to  my  own  experience,  are  the  best  for  alleviating  the 
pain.  By  placing  the  parts  in  a  proper  position — if  an  extremitv,  by  ele- 
vating it — the  analgesic  effects  of  the  above  remedies  are  materially  pro- 
moted. In^some  instances  it  is  proper  to  give  subcutaneous  injections 
of  morphine.  In  burns  of  the  second  degree,  when  blebs  are  present, 
it^  is  advantageous 'to  evacuate  the  blebs  through  punctures,  but  not  to 
remove  the  elevated  epidermis/to  cleanse  the  burned  area  in  the  usual 
way  with  antiseptic  solutions  (1  to  1,00(>  bichloride,  or  three-per-cent. 
carbolic-acid  solutions),  and  then  to  apply  an  antiseptic  powder  dress- 
ing— for  example,  zinc  oxide,  bismuth,  iodoform,  boric  acid,  etc.  As 
materials  for  dressings  it  is  a  good  plan  to  use  iodoform  gauze  or  steril- 
ised mull  covered  with  cotton,  oj  some  other  aseptic  material,  which 
allows  drying  to  take  place.  These  antiseptic  or  aseptic  di-y  powder 
dressings  I  consider  far  better  for  burns  than  the  other  kinds  of  dress- 
ings with  salves  (unguentum  simpl.,  cerussse,  diachylon,  vaseline,  etc.), 
or  washes  (lime-water  and  linseed  oil,  equal  parts),  or  solutions  of  ni- 
trate of  silver  (arg.  nitr.,  1  to  100  of  water).  The  dressing  dries  into 
a  firm  aseptic  scab,  which  can  be  left  uncovered  by  bandages  until  it 
falls  off  of  its  own  accord  from  the  healed  wound.     In  mild  burns  the 


490    INJURIES  AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

formation  of  simple  aseptic  scabs,  by  means  of  iodoform,  dermatol, 
bismuth,  or  zinc  oxide,  without  any  other  dressing,  is  a  very  excellent 
treatment.  After  careful  disinfection  of  the  burn,  Xitzsche  recom- 
mends covering  it  with  linseed  oil  varnish  (1  part  oxide  of  lead  dis- 
solved in  25  parts  of  boiled  linseed  oil,  to  which  is  then  added  five 
to  ten  per  cent,  of  salicylic  acid  M-hile  the  oil  is  hot) ;  over  this  a  layer 
of  cotton  is  jilaced,  and  pressed  down  as  firmly  as  possible  by  an  elastic 
bandage.  Healing  generally  follows  under  a  single  dressing.  The 
antiseptic  2>owder  dressings  are  particularly  good  for  burns  of  the 
third  degree.  In  this  way  the  decomposition  of  the  burned  tissues  is 
most  easily  prevented,  and  the  secretion  or  suppuration  is  kept  as  small 
as  possible.  The  treatment  of  burns,  like  any  other  wound,  should 
always  be  conducted  with  the  strictest  attention  to  antiseptic  rules,  and 
the  less  often  the  dressino-s  are  chano-ed  the  better.  A.  Bidder  recom- 
mends  painting  the  burned  area  with  thiolum  liquidum  or  powdering 
it  with  thiolum  siccum,  one  of  the  remedies  belonging  to  the  unsatu- 
rated sulphur  compounds  of  the  hydrocarbons.  In  extensive  hioms  the 
patient  should  be  placed,  when  feasible,  in  a  per^nanent  warm  hath 
(see  page  179).  The  covering  of  large  granulating  surfaces  with  skin 
can  be  hastened  by  the  transplantation  of  Thiersch  skin  grafts  (§  42),  or 
by  the  transplantation  of  large,  fresh  skin  flaps  with  pedicles  (§  41). 
This  is  the  best  way  of  preventing  the  development  of  cicatricial  con- 
tractures or  abnormal  adhesions.  If  cicatricial  contractures  or  disfijr- 
uring  strips  of  scar  tissue  have  developed  after  a  burn,  the  cicatrix 
should  be  excised  and  the  defect  closed  by  skin  flaps  with  pedicles  or 
Thiersch  skin  grafts.  In  the  milder  cases  of  contractures  following 
burns,  systematic  movements  and  massage  are  sufiicient.  The  indica- 
tions for  the  amputation  of  extremities  which  have  been  extensively 
burned  are,  in  general,  the  same  as  for  crushings  and  severe  contusions 
of  an  extremity.  The  amputation  should  be  performed  as  early  as  pos- 
sible after  the  first  symptoms  of  shock  have  subsided. 

In  very  extensive  burns  involving  a  large  portion  of  the  body,  the 
treatment  of  the  general  condition  of  the  patient  is  the  first  thing  to  be 
considered.  For  the  collapse  which  occurs  in  conjunction  with  the 
burn,  the  patient  should  be  placed  on  his  back,  wrapped  up  as  warmly 
as  possible,  and  stimulants  (wine,  whiskey,  grog,  black  coffee,  or  any 
warm  stimulating  drink)  should  be  administered.  The  subcutaneous 
injection  of  ether  or  camphor  is  also  advantageous,  as  is'the  temporary 
envelopment  of  the  extremities  in  elastic  bandages  to  drive  more  blood 
to  the  heart  (autotransfusion).  Eestless  patients  should  be  giv^en  mor- 
phine subcutaneously.  Blood-letting,  which  used  to  be  frequently  prac- 
tised, or  blood  transfusion,  should  be  condemned.     On  the  other  hand, 


goo.]  BURNS.  401 

'subcutaneous  salt  infusion  (see  pages  483,  484)  in  proper  cases  of  ai:a*- 
niia  or  of  collapse  are  worth  reconiniendiiig. 

Burns  from  Lightning. — According  to  Sonnenlmrg,  liglitning  pro- 
duces the  etk'Ct  of  an  electrical  shock  and  has  a  tearinij  and  burninur 
action.  Sometimes  the  one  and  sometimes  the  other  of  these  effects  is 
the  more  prominent.  If  people  and  animals  are  directly  struck  by 
lightning,  death  occurs  immediately  in  many  cases,  probably  as  a  result 
of  the  violent  electrical  shock  to  the  nerve  centres,  especially  those 
governing  respiration  and  circulation.  The  condition  of  a  person 
struck  by  lightning  is  often  precisely  similar  to  one  who  has  suffered  a 
commotio  cerebri.  Paralyses,  dysphagia,  disturbances  of  sight,  and 
other  nervous  phenomena,  are  also  observed.  Lightning  paralysis  has, 
in  general,  a  favourable  prognosis.  When  considering  the  paralyses  due 
to  strokes  of  lightning,  the  true  or  direct  strokes,  according  to  Lim- 
beck, must  Ije  careful! V  distinguished  from  those  occurrincf  indirect! v 
from  haemorrhage — in  the  brain,  for  instance.  In  the  true  lightning 
paralysis  two  stages  are  to  be  recognised  :  In  the  first,  we  have  to  deal 
with  a  direct  iniurv  to  the  nerves  and  muscles  caused  bv  the  lishtnintr, 
while'^n  the  second  we  have  th6  picture  of  a  traumatic  neurosis  (see 
page  250).  Occasionally  large  vessels  are  ruptured,  followed  by  death, 
and  now  and  then  extremities  are  completely  severed  from  the  body. 
The  effects  of  lightning  upon  the  skin  are  manifested  by  all  sorts  of 
changes,  varying  from  a  simple  drying  of  the  epidermis  to  the  severest 
biirns.  The  so-called  lightning-marks  upon  the  skin  are  well  known. 
They  consist  of  branching,  brownish-red,  zigzag  lines,  the  formation  of 
which  is  probably  connected  with  the  action  of  the  lightning  upon  the 
blood.  The  colouring  matter  is  set  free  from  the  red  blood-corpuscles 
by  the  electrical  action  of  the  lightning,  and  in  transuding  through  the 
walls  of  the  capillaries  or  vessels  forms  marks  which  correspond  to  the 
distribution  of  the  affected  vessels  (^Rollet). 

Occurrence  of  Lightning  Strokes  in  Man.— Sonnenburg  states  that  iu  Pnis- 
sia,  from  1S.54  to  IS.jT,  according  to  the  official  statistics,  five  hundred  and 
eleven  individuals  were  struck  by  lightning,  and  72'25  per  cent,  of  the  cases 
were  fatal.  The  great  majority  of  the  individuals  aflFected  were  struck  while 
at  work  in  the  fields.  The  statistics  of  Boudin  show  that  in  France  from 
18.S5  to  1864.  2.324  people  were  struck  by  lightning.  Dmnng  the  American 
civil  war.  in  the  summer  of  1864.  the  lightning  struck  amongst  the  Eighteentli 
Missouri  Regiment,  which  was  encamped  on  a  hill,  and  knocked  down  the  en- 
tire troop.  Almost  all  the  horses  and  eighteen  men  were  killed,  and  all  the 
rest  were  more  or  less  injured.  W  hen  a  row  of  men  or  animals  is  struck 
by  lightning  the  fii'^t  and  last  in  the  row  appear  to  be  the  most  endangered. 
It  is  noticeable,  a?;  Sonnenburg  has  correctly  remarked,  that  bodies  of  troops 
on  the  march  have  onlv  seldom  been  struck  bv  lightning. 


492    IXJrRIES  AND  SURGICAL   DISEASES  OF  THE  SOFT   PARTS. 

Treatment. — The  treatment  of  liglitning  strokes,  particularly  of  the 
constitutional  sj'mptoras,  is  purely  symptomatic.  The  treatment  of  the 
burns  is  just  the  same  as  described  above.  If  any  paralyses  are  left 
they  usually  disappear  entirely  under  eleetrieul  treatment. 

Sun-burn  Erythema  and  Eczema  Solare. — In  consequence  of  the  action  of 
the  sun's  rays  upon  the  uncovered  skin  superficial  burns  are  produced.  These 
occur  in  summer  time,  especially  in  tourists  and  moimtaineers.  The  skin 
becomes  red  and  swollen,  feels  hot,  and  is  more  or  less  painful  (erythema 
solare).  After  a  few  days  the  burned  layer  of  epidermis  comes  off  in  shreds 
from  the  underlying  parts.  Other  cases  pi-esent  a  more  eczematous  appear- 
ance, with  the  formation  of  blebs  {eczema  solare).  For  prophylaxis  against 
sun-burns,  sun-shades  should  be  carried  or  veils  worn,  etc.  People  with  irri- 
table skins  when  going  on  mountain  tours  should  cover  the  exposed  parts  of 
their  bodies  with  vaseline,  or  ungt.  litharg.  Hebrae,  or  with  starch  powder. 
The  burns  themselves,  as  long  as  severe  pain  exists,  should  be  treated  with 
applications  of  liq.  plumbi  subacetatis  dil.  and  ice,  or  with  ungt.  litharg. 
Hebrae  or  vaseline,  and  then  powdered  with  zinc  oxide  and  starch  (1  to  5 
to  10). 

Sun-stroke  or  Heat-Stroke. — AVe  have  yet  to  consider  the  so-called 
sun-stroke  or  heat-stroke  {insolation).  This  is  essentially  an  overheat- 
ing of  the  body,  and  often  terminates  very  quickly  in  death,  particu- 
larly in  hot  climates ;  but  the  affection  is  frequently  seen  in  summer, 
even  in  our  latitudes,  particularly  amongst  young  soldiers  who  have  to 
take  long  marches  in  very  hot  weather.  From  the  experiments  of 
Krishaber,  Schleich,  and  others,  we  know  that  the  temperature  of  a 
man's  body,  by  immersion  of  the  latter  in  a  hot  medium,  can  be  made 
to  rise  very  rapidly,  reaching,  for  example,  -1:0°  to  41°  C.  (104°  to 
105'8°  F.)  in  thirty  to  sixty  minutes.  Individuals  thus  treated  become 
restless,  the  respiration  gets  ver}-  frequent,  the  pulse  rises  to  160  or  180, 
the  production  of  urea  is  increased,  etc.  TJie  marked  rise  in  tempera- 
ture observed  in  individuals  who  have  been  sun-struck  coincides  with 
these  experiments.  In  a  case  wliich  terminated  fatally,  Biiumler  found 
the  temperature  of  the  patient  to  be  42'9°  C.  (109*4°  F.)  one  hour  after 
his  reception  into  the  hospital. 

The  symptoms  exhibited  in  sun-stroke  or  heat-stroke  are  very  char- 
acteristic. The  face  is  red,  the  respiration  rapid  and  sighing,  the 
liearfs  action  is  very  rapid,  and  the  pupils  are  dilated.  The  patient  is 
unconscious,  delirious,  and  convulsions  often  occur.  Death  takes  place 
in  collapse,  sometimes  very  suddenly.  In  other  cases  the  course  is  not 
so  acute ;  symptoms  of  collapse  are  then  especially  prominent,  from 
vsrhich  the  patient  may  recover  entirely.  The  decreased  secretion  of 
sweat  which  is  noticeable  in  "insolation"  is  important,  especially  as  re- 
gards the  treatment.     At  first  the  secretion  of  sweat  is  very  much 


§  90.]  BURNS.  403 

increased  in  individuals  who  work  or  march  in  very  hot  weather,  or 
with  the  sun  beating  directly  upon  the  head  ;  but  later  it  is  diminished, 
pjrobably  as  a  result  of  the  diminution  of  the  amount  of  water  in  the 
blood,  and  then  the  above-described  symptoms  of  sun-stroke  make  their 
appearance.  As  a  result  of  the  diminution  in  the  production  of  sweat. 
tjie  loss  of  heat  by  evaporation  becomes  so  much  diminished  that  the 
heat  balance  is  disturbed,  and,  in  consequence  of  the  increased  reten- 
tion of  heat,  the  temperature  of  the  body  rises  more  or  less  rapidly 
above  the  normal,  even  to  a  fatal  height  (Cohnheim).  'The  albuminuria 
as  well  as  the  ha?moglobinuria  sometimes  coming  on  in  horses,  for  ex- 
ample, after  severe  sweating,  are  ascribed  by  Maas  to  the  changes  in 
the  blood,  especially  in  the  serum  albumen  and  the  red  blood-corpus- 
cles, due  to  the  great  loss  of  water. 
aJ^  The  cause  of  death  in  sun-stroke  or  heat-stroke  is  partly  the  over- 
"^  heating  of  the  body  and  partly  the  great  loss  of  water  from  the  body, 
or  the  alteration  in  the  composition  of  the  blood. 

Occurrence  of  Sun-stroke. — Meyer  has  recently  reported  a  great  number  of 
sun-strokes  affecting  harvest  labourers  almost  like  an  epidemic  in  the  sum- 
mers of  1873  and  18S0.  He  ascribes  death  to  cardiac  paralysis,  due  to  the  in- 
creased temperature  of  the  body  and  to  an  alteration  in  the  blood  which  he 
considers  uraemic.  He  distinguishes  three  stages  of  the  disease — a  prodromal 
stage,  a  stage  of  excitement,  and  a  stage  of  depression.  Amongst  the  numer- 
ous cases,  only  one  terminated  fatally  from  meningitis  and  bilateral  pneu- 
monia. American  physicians  have  also  described  regular  epidemics  of  sun- 
stroke. In  many  campaigns  sun-strokes  have  formed  a  considerable  part  of 
the  diseases  and  deaths.  As  Sonnenburg  mentions,  the  Crusadei*s  appear  to 
have  suffered  especially  large  losses  by  sun-stroke  and  beat-stroke.  On  the 
march  through  Bithynia  and  Phrygia.  in  July.  1099.  five  hundred  men  often 
perished  on  a  single  day  from  sun-stroke.  During  the  American  war  of 
secession  (1861-'64)  there  were  seventy-two  hundred  sun-strokes,  with  three 
hundred  and  nineteen  deaths.  As  a  result  of  a  forced  march  during  very 
hot  weather  in  1848.  Sonnenburg  states  that  in  the  Nineteenth  Infantry 
Regiment  of  the  German  army  twenty -nine  men  died.  It  is  a  particularly 
fatal  mistaketq_keep  sol  djers,  while  manoeuvring  or  on  the  march,  from 
drinking. 

Treatment  of  Sun-stroke. — It  is  my  belief  that  the  treatment  of  sun- 
stroke or  heat-.-:truke  is  dependent  upon  the  last-mentioned  facts. 
For  prophylactic  reasons,  it  should  be  stated  that  the  withholding  of 
drink  increases  the  danger  of  insolation.  Hence  a  regular  supply  of 
water  to  individuals  while  at  work  or  on  the  march  is. to  be  regarded, 
to  a  certain  extent,  as  a  protection  against  sun-stroke.  AVhen  the 
dreaded  accident  of  sun-stroke  has  occurred,  our  efforts  should  be  di- 
rected towards^lowering  the  temperature  of  the  body, 'stimulating  the 


494    INJURIES  AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

secretion  of  sweat,  and  combating  the  weakness  of  the  lieart.  We 
try  to  meet  these  indications  by ieold  applications  and  cold  baths;  by 
introducing  large  q^uantities  of  water  into  the  stomach  and  intestinal 
canal  ;  by  the  administration  internally  of  stimulants,  particularly  alco- 
liol ;  by  subcutaneous  injection  of  ether  and  camphor,  and  by  keeping 
the  patient  as  quiet  as  possible.  Many  authorities  have  opposed  the 
energetic  use  of  cold  applications,  cool  baths,  etc.,  and  advocate  warm 
baths  and  warm  rubbing.  I  believe  that  in  sun  strokes  as  vigorous  an 
attempt  as  possible  should  be  made  to  lower  the  temperature  of  the 
body  by  cold  applications,  and,  when  feasible,  by  cool  baths.  Venesec- 
tion should  not  be  employed ;  it  is  useless,  and,  in  fact,  usually  causes 
marked  collapse. 

§  91.  Effects  of  Cold  (Freezing). — There  are  usually  distinguished,  as 
in  burns,  three  different  degrees  in  the  effects  of  cold  upon  the  skin. 
The  first  degree  is  characterised  by  a  superficial,  erythematous  inflam- 
mation,'the  second  by  the  formation  of  blebs,  and^the  third  by  eschar 
formation.  The  peripheral  portions  of  the  body — the  toes  and  fin- 
gers, the  feet  and  hands,  the  nose  and  ears — are  especially  exposed  to 
the  danger  of  freezing. 

Symptoms  of  Freezing. — In  cases  of  freezing  there  usually  occurs, 
in  the  first  place,  a  contraction  of  the  cutaneous  vessels,  in  consequence 
of  which  the  affected  skin  area  appears  pale,  and  in  many  individu- 
als corpse-like,  particularly  when  the  fingers  are  involved  ;  this  is  often 
a  result  of  the  action  of  a  very  slight  amount  of  cold.  After  the  first 
contraction  of  the  vessels  there  follows  a  dilatation  throughout  the 
affected  area ;  the  latter  takes  on  a  deep  red  colour,  and  a  more  or 
less  pronounced  swelling  develops,  which  causes  an  itching  or  burn- 
ing sensation.  Severe  pains  may  also  occur,  especially  when  the  frozen 
parts  are  rapidl}'  warmed.  In  the  first  degree  of  freezing  this  inflam- 
matory redness  and  swelling  disappear  permanently  within  a  few  days. 
But  not  infrequently  the  frozen  area  of  skin  has  a  tendency  to  become 
affected  by  a  constantly  recurring  redness,  particularly  the  skin  of  the 
nose,  ears,  toes,  and  fingers.  It  may  even  happen  that  such  cutaneous 
areas,  especially  the  point  of  the  nose,  may,  in  consequence  of  a  sort 
of  vascular  paralysis,  remain  red  throughout  life.  The  so-called  chil- 
blains {perniones)  come  from  a  repeated  slight  freezing  of  the  fingers 
and  toes.  The  extensor  surfaces  especially  become  the  seat,  in  such 
cases,  of  a  dark  or  bluish- red  swelling,  which  has  a  tendency  to  ulcer- 
ate, and  the  patient  is  annoyed  l)y  severe  itching  and  burning,  particu- 
larly in  bed,  during  the  change  from  cold  to  thawing  weather,  and  in 
summer.  Individuals  who  have  to  change  constantly  from  cold  to  hot 
atmospheres  are  very  apt  to  suffer  from  chilblains.     Women,  and,  as 


§91.]  EFFECTS  OF  COLD.  495 

a  general  tiling,  anceniic  people,  appear  to  be  most  snsceptil)le  to  these 
mild  degrees  of  freezing, 

lu  a  frost-bite  of  the  second  deyree  the  affected  area  of  skin  assumes 
a  deep  red  or  bluish  colour  and  is  covered  with  blebs.  In  such  cases  it 
is  a  matter  of  great  uncertainty  as  to  whether  there  will  finally  occur  a 
complete  restitutio  ad  integrum^  or  whether  we  do  not  have  to  deal 
with  a  frost-bite  of  the  third  degree,  with  its  termination  in  eschar 
formation  or  in  gangrene.  Speaking  generally,  the  prognosis  of  the 
second  degree  of  frost-bite  is  nnich  mure  unfavourable  than  is  the  case 
with  burns.  Whenever  blebs  develop  after  a  frost-bite  there  will 
follow  in  the  majority  of  cases  a  gangrene  of  greater  or  less  depth.  It 
is  very  suspicious,  in  such  cases,  when  the  absence  of  sensibility  persists 
for  several  days,  and  when  the  area  of  skin — ajmrt  from  the  blebs — ap- 
pears to  be  almost  normal.  In  the  pronounced  cases  of  freezing  of  the 
third  degree  terminating  hi  mortification  of  the  affected  tissues,  the  parts 
involved  are  usually  entirely  devoid  of  sensation,  of  a  dark  blue  colour, 
and  covered  with  blebs  and  scabs ;  there  is  no  circulation,  as  the  prick 
of  a  needle  draws  no  blood.  I  saw  a  case  of  freezing  like  this,  involv- 
ing both  feet  and  legs,  in  a  deserter  who  had  wandered  many  days  in 
the  forest  during  extreme  cold  with  insufficient  clothing ;  both  legs 
were  amputated  and  the  patient  recovered.  When  extremities  are 
entirely  frozen  like  this,  parts  of  the  toes  can  be  broken  off  through 
the  joints  like  glass. 

Effect  of  Cold  upon  the  Body. — The  constitutional  effects  of  cold  upon 
the  human  organism  is  a  matter  of  great  interest.  If  an  individual  is 
placed  in  a  cold  medium,  he  will  lose  heat  the  more  rapidly  the  lower 
the  temperature  of  the  medium  and  the  quieter  he  remains.  As  long 
as  a  person  is  in  a  position  to  perform  active  movements  he  can  suc- 
cessfully withstand  severe  degrees  of  cold,  such  as  —  42°  to  —  iS''  C. 
(—  43°  to  —  49°  F.).  When  the  niuscles  become  quiet  the  danger  of 
freezing  is  particularly  great. 

Experiments  in  the  Reduction  of  the  Temperature  of  Animals.— Walther, 
Howarth,  and  Cohnheim,  experimenting  with  animals,  have  studied  the 
consequences  of  cooling  off  the  organism.  If  a  rabbit  or  a  small  dog  is  im- 
mersed to  the  neck  in  water  at  a  temperature  of  about  0°  C,  or  placed  in  a 
small  vessel  surrounded  bv  a  cooling  mixture,  in  which  movement  is  impos- 
sible, the  temperature  g-radually  sinks.  If  the  animal  is  kept  in  the  cold 
medium  until  the  rectal  tempei'ature  becomes  18°  to  20"  C  (68"  F.),  as  a  result 
of  this  cooling  off  a  general  paralytic  condition  becomes  evident.  The  ani- 
mal is  no  longer  able  to  stand  on  its  legs,  and  lias  as  though  dead,  the  con- 
tractions of  the  heart  are  weak  and  slow  (16  to  20  beats  in  the  minute),  the 
frequency  of  respiration  is  also  diminished,  peristalsis  of  the  intestine  ceases, 
and  the  urinary  bladder,  though  filled  to  distention,  is  not  emptied.    The  eyes 


496    INJURIES   AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

are  widely  opened,  the  cornea  shows  ahiiost  no  reaction,  and  the  pupils  are 
very  widely  dilated  and  almost  entirely  insensitive  to  light.  If.  after  the  ani- 
mal lias  been  cooled  down  to  a  temperature  of  18°  C.  (64 --l"  F.),  he  is  allowed 
to  remain  in  the  cold  medium  still  longer,  death  usually  soon  occurs  in  the 
majority  of  cases  from  cardiac  paralysis.  Animals  whose  temperature  has 
been  reduced  to  18°  C.  ordinarily  die  when  allowed  to  lie  quietly  at  room 
temperatures  ;  but  their  temperature  will  again  rise  to  the  normal  if  they  are 
placed  in  a  hot  medium — for  example,  in  a  vessel  at  a  temperature  of  40°  C. 
(104°  F.).  At  first  the  temperature  rises  veiy  slowly  to  about  30°  C.  (86°  F.), 
and  then  more  rapidly ;  within  about  two  to  three  hours  the  temperature  of  the 
animal  rises  from  18°  to  39°  C.  (644°  to  102°  F.).  The  chilled  animal  can  also 
be  made  to  become  warm  again  by  artificial  respiration.  As  the  temperature 
of  the  body  rises  the  general  paralytic  condition  disappears,  the  activity  of  tbe 
heart  and  lungs  increases,  intestinal  peristalsis  reappears,  the  urinary  bladder 
is  emptied,  and  finally  the  brain  regains  its  function  and  the  animal  is  again 
full  of  life.  But  many  of  these  animals  die  later  on  after  they  have  re- 
covered their  normal  temperature,  and  occasionally  such  animals  are  even 
subject  to  elevations  of  temperature  with  subsequent  pronounced  emaciation. 

According  to  Catiano,  death  from  freezing  is  due  essentially  to  cerebral ^b' 
anaemia  with  secondai-y  paralysis  of  the  respiratory  nerves.  ^ 

It  is  not  known  at  what  temperature  man  ceases  to  live.  Tempera- 
tures of  24°  to  26°  C.  (75-2°  to  78-8°  F.)  in  the  rectum  have  been  re- 
peatedly recorded  during  the  winter  time  in  drunken  people  who  after- 
wards— generally  within  a  few  hours — completely  recovered.  Cohn- 
heim  believes  that  a  complete  and  rapid  recovery  is  dotibtful  when  the 
temperature  in  man  goes  down  to  20°  to  18°  C.  (68°  to  64"2°  F.).  The 
symptoms  manifested  by  man  correspond  entirely  with  those  obtained 
by  animal  experimentation.  When  a  person  becomes  very  cold  there 
is  a  pronounced  apathy  and  sleepiness,  the  ptilse  and  respiration  are 
slow,  and  the  pupils  are  widely  dilated  and  react  sluggislily.  Death 
from  freezing  is  favoured  by  diminished  muscular  movement.  Accord- 
ing to  Sonnenburg,  thirty-six  per  cent,  of  those  who  are  frozen  are 
drunk  at  the  time. 

Treatment  of  Freezing. — In  treating  the  mildest  grade  of  frost-bite 
the  affected  part  should  not  be  warmed  too  rapidly,  but  should  be  rubbed 
with  snow  or  ice  water  and  then  wrapped  in  wet  cloths.  A  great 
number  of  remedies  have  been  suggested  for  chilblains.  It  is  always 
important  to  attend  to  the  general  condition  of  individuals  with  a 
tendency  to  chilblains,  and,  as  a  prophylactic  measure,  to  recommend 
warm  coverings  for  the  hands  and  feet  when  the  cold  period  of  the 
year  comes  on.  When  chilblains  are  present  we  try  rubbing  the 
parts  with  snow  and  ice  water,  ice  poultices,  a  foot  bath  of  ice  water 
followed  by  the  application  of  wet  cloths,  painting  the  parts  with  col- 
lodion,   traumaticin,  glue,   enveloping  them  with  strips  of   adhesive 


§92.]  SUBCUTANEOUS  INJURIES  OF  SOFT   PARTS.  497 

plaster,  tlie  application  of  tinct.  iodi.  followed  by  a  warm,  moist  poul- 
tice, mild  caustics,  such  as  dilute  hydrochloric  acid  (1  to  25  or  30  of 
water),  tinct.  cantharid.,  etc.  Various  kinds  of  salves  have  been  recom- 
mended. Excoriated,  ulcerated  frost-bites  are  best  treated  with  iodo- 
form or  zinc  oxide  and  starch,  or  with  ungt.  litharg.  Ilebnie  (ungt. 
diachylon),  Avith  or  without  starch,  and  oxide  of  zinc.  For  red  noses 
following  frost-bite  I  should  recommend  punctures  made  not  too  deep 
with  the  needle  point  of  the  Paquelin  cautery,  or  the  galvano-cautery, 
which  causes  the  redness  to  disappear  without  giving  rise  to  a  visible 
scar. 

In  cases  of  extensive  and  deep  freezing  of  the  second  and  third 
degree  involving  an  extremity,  vertical  suspension  of  the  limb  should 
be  immediately  employed  to  facilitate  the  restoration  of  the  circulation 
in  the  frozen  parts.  Wet  applications  may  be  combined  with  the  ele- 
.  vated  position  to  stimulate  the  local  vasomotor  ganglia.  If  there  is 
necrosis  of  the  tissues,  antiseptic  dressings  with  iodoform,  or  with  iodo- 
form and  charcoal,  naphthaline,  etc.,  or  antiseptic  continuous  irriga- 
tion, should  be  used  as  for  burns.  If  the  frozen  surface  is  very  large 
the  permanent  water  bath  should  be  employed  (see  page  180).  If  gan- 
grene of  an  extremity  develops,  amputation  or  disarticulation  should 
not  be  undertaken  prematurely,  but  antiseptic  treatment  should  be 
kept  up  until  the  line  of  demarcation  has  become  distinct.  Spread- 
ing inflammation  and  suppuration  are  to  be  combated  by  multiple  in- 
cisions, etc. 

The  treatment  of  freezing  of  the  entire  body  is  as  follows  :  In  the 
first  place,^tlie  person  who  has  been  frozen  must  not  be  warmed  too 
suddenly.  He  should  be  carried  into  an  unheated  room,  rubbed  with 
cold  wet  cloths,  and- then  placed  in  a  bath  at  a  temperature  of  16° 
to  18°  C.  (60-8°  to  64-4°  F.),  wliich  is  gradually— within  two  to  three 
hours — brought  up  to  30°  C.  {SQ°  F.).  It  is  often  necessary  and 
always  very  useful  to  perform  artificial  respiration.  ''Ether  and  cam- 
phor are  given  subcutaneously,  and,  as  soon  as  the  patient  can  swallow, 
alcoholic  stimulants  are  freely  administered.  'Wrapping  the  extremi- 
ties in  cold  wet  cloths  is  excellent  for  the  severe  pains  in  the  limbs 
whicEToccur  as  Uie^atTent  returns  to  life.  Bergmann  and  Eeyher  rec- 
ommend suspension  of  the  frozen  extremities  at  the  earliest  possible 
moment,  to  limit  the  gangrene.  There  should  be  no  hesitatiqn_in  ap;- 
plying  vertical  extension  to  all  four  extremities.  vX 

§  92.  Subcutaneous  Injuries  of  Soft  Parts. — The  most  common  and 

ijuportant  subcutaneous  injury  wliich  the  soft  parts  suffer  is  contusion. 

It  usually  results  from  a  bruising  or  crushing  produced  l^y  some  blunt 

object,  })j  a  thrust,  blow,  or  fall.     The  soft  parts  are  either  squeezed 

32  ■" 


498    INJURIES   AND   SURGICAL   DISEASES  OF  THE   SOFT   PARTS. 

together  as  a  wliole,  or  pressed  against  a  neighbouring  bone.  The  de- 
gree of  the  crush,  of  course,  varies  all  the  way  from  a  slight  bloody 
discolouration,  a  bloody  suffusion  or  suggillation,  to  a  crushing  of  the 
bones  and  soft  parts  into  a  pulpy  mass.  In  many  individuals,  such  as 
the  so-called  bleeders  (see  page  57),  a  comparatively  large  effusion  of 
blood  not  infrequently  follows  a  trifling  contusion  of  the  tissues.  Fur- 
thermore, spontaneous  subcutaneous  hiemorrhages  are  not  uncommon 
in  bleeders. 

The  different  soft  tissues  of  the  body  possess  a  very  unequal  power 
of  resisting  a  contusing  force.  As  Gussenbauer's  experiments  teach, 
and  as  daily  experience  proves,  the  loose  connective  tissue  and  the 
small  vessels  and  capillaries  it  contains  have  the  least  po\vers  of  resist- 
ance. The  skin,  the  fascia,  the  tendons  and  larger  vessels  exhibit  a 
remarkable  resistance  to  tlie  effects  of  a  contusing  force.  In  general, 
two  deofrees  of  contusion  can  be  distinguished,  the'  first  being  the  con- 
tusion  with  preservation  of  the  affected  parts,  and  me  second  with  their 
destruction  (mortification,  necrosis). 

Symptoms  of  Contusion. — The  most  important  of  the  symptoms  of  a 
contusion  of  the  subcutaneous  tissues  is  h(Bmorrhage.  In  the  majority 
of  cases  the  extravasated  blood  comes  from  the  capillaries  and  veins, 
the  arteries  possessing  great  powers  of  resistance  to  violence  inflicted 
by  a  blunt  object.  As  a  result  of  the  laceration  of  the  lymph  vessels, 
there  is  also  an  extravasation  of  lymph,  and  it  sometimes  happens 
that  the  extravasation  is  made  up  mostly  of  lymph.  This  lymph  ex- 
travasate  may  form  a  fluctuating  tumour,  and  usually  is  made  up  of  a 
citron-yellow  or  a  slightly  reddish-coloured  fluid  having  the  composi- 
tion of  lymi)h  or  blood  serum.  According  to  Gussenbauer,  these 
lymph  effusions  are  particularly  apt  to  occur  when  the  skin  is  more 
or  less  displaced  by  a  traumatism  from  its  position  in  relation  to  the 
underlying  parts.  This  displacement  causes  a  laceration  of  the  lyin- 
phatic  vessels  which  permeate  the  subcutaneous  cellular  tissue.  The 
lymph  effusions  are  consequently  usually  located  in  the  subcutaneous 
cellular  tissue.  As  a  general  thing,  the  hemorrhage  in  subcutaneous 
injuries,  even  when  large  vessels  are  ruptured,  is  not  dangerous,  and, 
for  the  most  part,  soon  stops  in  consequence  of  the  rapid  coagulation 
which  usually  follows  contusions.  The  extravasated  blood  is  either 
evenly  distributed  throughout  the  contused  tissues  as  a  htemorrhagic 
infiltration,  or  it  forms  small,  circumscribed  collections  which  are 
called  ecchymoses  or  suggillations.  The  larger  collections  of  blood 
are  called  hsematomata ;  suffusions,  on  the  other  hand,  designate  more 
superficial,  large,  spread-out  collections  of  blood.  The  extravasated 
blood  distributes  itself  through  the  tissues  in  (he  direction  of  least 


%[)2.]  SUBCUTANEOUS   INJURIES  OF  SOFT   PARTS.  499 

resistance,  especially  between  the  fasciculi  of  connective  tissue,  be- 
tween the  muscles,  in  the  subcutaneous  cellular  tissue,  etc.  If  the 
bleeding  takes  place  into  a  free  cavity,  a  bursa  or  a  joint,  or  into  one 
of  the  cavities  of  the  body,  a  large  collection  of  blood  may  result. 
The  collections  of  blood  in  the  cavities  of  the  body  have  their  special 
nomenclature,  an  effusion  of  blood  into  a  joint  being  called  liaemar- 
thros  ;  into  the  pleura,  luemothorax  or  lu\?matothorax,  etc.  Other  blood 
effusions  have  likewise  received  particular  names,  according  to  the 
locality  in  which  they  occur — for  example,  the  blood  tumour  on  the 
head  of  a  newborn  infant  is  called  a  cephalo-hsematoma ;  a  haemor- 
rhage into  the  brain,  an  apoplexy,  etc. 

The  haemorrhages  into  the  large  cavities  of  the  body  are,  of  course, 
daiigerous,  and  are  not  infrequently  fatal,  partly  because  of  the  amount 
of  blood  poured  out,  which  has  been  able  to  escape  freely,  and  "partly 
Ijecause  of  the  pressure  of  the  extravasation  upon  organs  such  as  the 
heart  or  brain,  which  are  necessary  for  the  preservation  of  life.  It  is 
well  known  that  no  less  danger  attaches  to  haemorrhages  into  the  brain 
itself,  the  so-called  apoplexies  by  which,  apart  from  other  disturbances, 
the  substance  of  the  brain  is  partially  destroyed,  and  rapidly  develop- 
ing paralyses  and  death  are  produced. 

As  the  larger  arteries  are  in  general  deeply  located  in  the  soft  parts, 
and^heir  tough,  elastic  walls  are  not  easily  torn,  it  but  rarely  happens 
that  they  suffer  a  subcutaneous  rupture.  But  if  it  does  happen  as  a 
result  of  unusual  violence,  a  pulsating  tumour  may  be  formed — a  so- 
called  tramrmdc^ajieurysm  (§  95,  Aneurysm).  When  the  extravasated 
blood  comes  from  an  artery  or  from  the  larger  veins  the  Irydrostatic 
pressure  in  the  connective-tissue  spaces  usually  soon  rises  to  such  an 
extent  as  to  arrest  the  bleeding,  the  rupture  in  the  artery  being  closed 
by  a  coagulum.  But  the  presence  of  pulsation  in  an  extravasation  of 
blood  does  not  in  all  cases  indicate  a  subcutaneous  injury  to  an  artery. 
The  pulsation  may  be  only  apparent,  and  due  to  the  rise  and  fall  of  the 
more  or  less  tense  extravasation  caused  by  the  pulsation  of  the  under- 
lying uninjured  artery.  If  the  apparent  pulsation  of  a  tumour  is  com- 
municated from  an  adjoining  artery,  the  tumour  shows  no  increase  in 
all  dimensions  with  each  systole,  but  only  in  a  direction  at  right  angles 
to  the  underlying  artery.  On  the  otlier  hand,  an  artery  may  have  re- 
ceived an  injur}',  and  yet,  on  account  of  the  thickness  of  the  overlying 
layers  of  tissue,  it  will  be  impossible  to  detect  pulsation. 

The  recognition  of  extravasated  blood  when  the  haemorrhage  is 
superficial  presents  no  difficulties.  The  haemorrhages  into  the  skin 
and  subcutaneous  cellular  tissue  are  usually  seen  immediately.  In 
such  cases  the  skin  has  a  dark-red  or  violet  colour  and  the  greater  the 


500    INJURIES  AND   SURGICAL  DISEASES  OF   THE  SOFT   PARTS. 

haemorrhage  the  more  extensive  is  tlie  doughy  and  fluctuating  tumour. 
As  a  result  of  the  distribution  of  the  colouring  matter  of  the  blood  in 
the  tissues  of  the  cutis,  there  occur  within  the  first  few  days  following 
the  injury  various  shades  of  discolouration,  of  which  green,  dark  green 
and  yellow  usually  predominate ;  they  often  persist  a  week  or  so  as  a 
symptom  of  the  contusion  which  the  skin  has  suffered.  Tlie  larger 
the  swelling  the  greater  is  the  subcutaneous  extravasation  of  blood. 
The  more  deeply  situated  extravasations  in  the  extremities  cannot  be 
recognised  solely  by  inspection  ;  it  is  usually  necessary  to  make  use  of 
palpation  of  the  contused  soft  parts.  As  a  general  thing,  crushed  soft 
parts  are  rendered  hard  by  the  bloody  infiltration ;  they  are  thick- 
ened and  give  a  feeling  of  resistance.  In  the  worst  degree  of  contu- 
sions, on  the  other  hand,  such  as  those  in  which  the  soft  parts  and 
the  bones  are  crushed  to  a  pulp  by  the  wheel  of  a  heav^y  waggon,  the 
alfected  parts  are  changed  into  a  shapeless  mass  devoid  of  circulation, 
with  or  without  preservation  of  the  cutaneous  coverings. 

The  comparatively  rare  extravasations  of  pure  lymph  are  distin- 
guished from  blood  extravasations  by' their  slower  increase  in  volume, 
''by  the  absence  of  discolouration  ofjthe  skin,  and^qf  all  the  other  symp- 
toms which  occur  as  a  result  of  the  coagulation  of  blood  and  of  the 
presence  of  the  colouring  matter  of  blood  in  the  tissues. 

Fever  in  Subcutaneous  Injuries. — Following  subcutaneous  injuries  of 
tissue  there  will  sometimes  be  fever,  and  yet  there  will  be  n^  symp- 
toms worth  speaking  of  which  indicate  either  inflammation  or  sup- 
puration ;  thus  in  subcutaneous  extravasations  of  blood  or  subcutaneous 
fractures  there  will  sometimes  be  an  elevation  of  temperature  to  101° 
to  102°  F.,  or  even  as  high  as  104°  F.  The  cause  of  this  fever  is  to 
be  ascribed,  in  these  cases,  to  the  taking  up  of  the  products  of  destruc- 
tion in  the  tissues  by  the  circulating  fluids  of  the  body  (see  §  62,  Fever). 

In  addition  to  the  elements  of  the  blood  and  lymph,  ingredients  of 
the  contused  tissues  are  also  taken  up  into  the  circulation,  especially 
fat,  which  may  enter  the  blood  and  lymph  vessels,  thus  causing  exten- 
sive fat  emboli  in  the  lungs  and  brain.  Fat  emboli  are  particularly 
apt  to  occur  when  the  marrow  of  a  bone  is  injured,  as  in  a  fracture. 
When  we  come  to  the  latter  subject  these  emboli  will  be  discussed 
more  fully. 

Disturbance  of  Function. — The  disturbance  of  function  exhiluted  by 
the  contused  soft  parts  varies  greatly  according 'to  the  portion  of  the 
body  affected  and  the  degree  of  the  contusion.'^ 'A  contused  joint  in 
which  there  is  a  large  intra-articular  extravasation  of  blood  naturally 
has  its  mobility  affected.  A  crushed  muscle  which  has  suffered  com- 
plete rupture  will  be  unable  to  contract,  and  the  rupture  of  a  nerve, 


§92.]  SUBCUTANEOUS  INJURIES  OF  SOFT   PARTS.  501 

such  as  a  mixed  nerve  in  an  extremity,  will  give  rise  to  a  paralysis  of 
the  muscles  which  it  supplies. 

The  pain  wliich  is  felt  in  a  contusion  at  the  moment  the  violence  is 
exhibited  varies  greatly,  according  to  the  richness  of  the  nerve  supply 
in  the  affected  portion  of  the  body,  and  'according  to  the  amount  of 
crushing  sustained  by  the  nerves.  If  from  the  effects  of  the  violence 
a  large  sensory  nerve  is  injured,  the  pain  at  the  moment  the  injury  is 
received  is  very  severe,  and  the  person  who  has  been  injured  feels  the 
pain  of  the  contusion  not  only  at  the  point  where  the  injury  was  re- 
ceived, but  usually  all  along  the  course  of  the  nerve,  and  so  at  points 
widely  removed  from  the  injury. 

Results  of  the  Contusion  of  a  Nerve. — (A^ncussion  of  the  nerve  sub- 
stance is  particularly  apt  to  occur  in  contusions  of  the  skull.  When  a 
blow  is  received  on  the  head,  the  symptoms  of  concussion  of  the  brain 
{commotio  cerehri)  are  very  plain,  and  eventually  may  l)e  combined 
with  so-called  focal  symptoms  indicating  an  injury  to  some  particular 
part  of  the  brain,  or  with  symjitoms  of  compression  from  extravasated 
blood  which  may  collect  between  the  brain  and  the  skull  (see  Special 
Surgery).  In  other  cases  the  synaptoms  of  concussion  of  the  brain 
and  spinal  cord  are  produced  indirectly,  as  by  falls  upon  the  feet.  In 
the  same  way  a  concussion  of  the  nervous  system  or  a  contusion  of 
a  nerve  due  to  an  injury  to  any  part  of  the  body  can  reflexly  affect 
the  central  nervous  system  to  such  a  degree  as  to  give  rise  to  the  set 
of  symptoms  known  as  shock  (see  §  63). 

The  severity  of  the  injury  to  the  skin  is  of  the  greatest  importance 
as  regards  the  subsequent  course  of  the  contusion,  but  the  extent  of 
this  injury  cannot  always  be  determined  from  the  first.  The  severity 
of  the  injury  to  the  skin  depends 'upon  the  shape  of  the  body  inflicting 
the  contusion  and  the  force  with  which  it  acts,  and'upon  the  elasticity 
and  thickness  of  the  skin,  which  \^ry  in  different  portions  of  the  body 
and  in  different  individuals. 

If  the  skin  is  contused  to  such  an  extent  that  all  the  vessels  are 
ruptured  and  the  circulation  in  the  affected  area  is  stopped,  the  natural 
consequence  is  death  or  necrosis  of  the  tissues  thus  deprived  of  nutri- 
tion. An  area  of  skin  like  this  contains  no  blood,  and  none  flows  when 
an  incision  is  made  into  it,  and  no  pain  from  the  incision  will  be  felt 
by  the  patient.  Sometimes  an  apparently  dead  portion  of  skin  re- 
covers, the  circulation  becomes  established  here  and  there,  and  tlien 
the  entire  thickness  or  the  entire  area  of  contused  skin,  does  not  per- 
ish. The  subcutaneous  soft  parts  and  the  bones,  like  the  skin,  may 
also  suffer  a  primary  necrosis  in  consequence  of  a  crushing  injury. 
There  is  another  kind,  of  death  of  tissue  which  is  secondary  in  its 


502    INJURIES  AND  SURGICAL  DISEASES  OP  THE  SOFT  P.VilTS. 


nature   and    caused  l)j  the  inflammation  that   takes   place   after   the 

injury. 

If  the  integrity  of  the  skin  has  been  preserved,  absorption  of  the 

subcutaneous  extravasation  of  blood  usually  takes  place  without  any 

particular  disturbance.  During  the  iirst 
few  days  following  the  injury  the  con- 
tused skin  exhibits  the  characteristic 
changes  which  take  place  in  the  colour- 
ing matter  of  the  blood.  The  discoloura- 
tion, which  at  the  outset  is  dark  blue  or 
bluish  red,  becomes  brownish,  dark  green, 
green,  and  Anally  yellow  ;  the  yellow 
stain  often  persists  for  weeks  or  months. 
Occasionally  the  areas  of  discoh)ured  skin 
are  very  extensive. 

Absorption  of  the  Blood  Extravasation. 

— The  extravasated  blood  is  absorbed  as  fol- 
lows: First  the  fluid  portiou  of  the  coaguluai 
is  taken  up  and  carried  off  by  the  lymphatic 
vessels,  and  then  the  fibrinous  portiou  be- 
comes liquefied  and  is  likewisa  absorbed  by 
the  lymphatics.  'Some  of  the  colourless 
blood-corpuscles  disintegrate  when  coagula- 
tion takes  place,  vvliile  others  are  forced  out 
of  the  clot  as  it  coagulates,  or  leave  it,  accord- 
ing to  Cohnheim,  by  spontaneous  locomotion. 
The  chief  interest  in  the  resorption  of  extravasated  blood  centres  upon  the 
fate  of' the  red  blood  corpuscles.     Many  of  them  get  into  the  lymph  channels 

and  are  carried  by  the  lymph  current  to 
the  nearest  lymphatic  glands,  where 
they  occasionally  accumulate  in  such 
numbers  as  to  cause  marked  swelling  of 
the  glands  and  to  make  a  section  of 
their  parenchyma  present  an  evenly  dis- 
tributed dark-red  appeai'ance.  I  found 
in  a  case  of  a  fractured  pelvis,  with  a 
subcutaneous  rupture  and  contusion  of 
the  psoas  muscle,  a  very  extensive  col- 
lection of  red  blood-cells  in  the  retro- 
peritoneal lymph  glands.  Similar  ac- 
cumulations of  red  blood-corpuscles  or 
of  blood  pigment  (Fig.  311)  were  also 
present  in  other  organs,  particularly  the 
liver.  These  observations  show  that  red  blood-corpuscles  are  taken  up  in  great 
numbers  by  the  lymph  channels  and  enter  the  circulation.  Another  portion 
of  the  red  corpuscles  disappear  in  loco  by  granular  degeneration  after  they 


Fio.  310. — Collection  of  blood  in  a 
retro-peritoneal  lymph  gland  re- 
sulting from  a  subcutaneous  lac- 
eration and  contusion  of  the 
psoas  muscle  with  fracture  of  the 
pelvis.     X  30. 


Fig.  311. — Collection  of  blood  in  the  liver 
after  subcutaneous  laceration  and  con- 
tusion of  the  psoas  muscle  with  frac- 
ture of  the  pelvis,     x  80. 


g92.]       \         SUBCUTANEOUS  INJURIES  OF  SOFT  PARTS.  503 

have  previously  become  decolourised  by  loss  of  their  colourin;j:  matter.  The 
colouring  matter  of  the  blood  is  dill'used  through  the  surrounding  parts  and 
a  portion  of  it  is  simply  absorbed,  while  another  portion  is  changed  into 
crystalline  haimatoidin — i.  e.,  into  oblique  rhoiuboid  crystals  about  U'l  milli- 
metre long,  of  a  yellowish-red  to  brick-red  colour.  Together  with  these  crys- 
talline forms  there  also  occur  orange-yellow  needles  and  small  angular  or 
indentated  rust-coloured  particles.  The  haematoidin  is  not  formed  solely  by 
direct  transformation  of  free  red  blood-corpuscles,  but  also  originates  intra- 
cellularly — that  is,  the  red  corpuscles  are  taken  up  by  the  lymph  corpuscles 
and  the  colourless  blood-corpuscles  and  are  here  changed  into  pigment 
(Langhans). 

Other  Termmations  of  Extravasations  of  Blood. — The  most  satisfac- 
torj  termination  for  an  extravasation  of  blood  is  its  complete  ab- 
soi'ption  in  the  manner  described  above.  When  the  extravasation  is 
diffuse,  absorption  is  the  commonest  termination.  The  particles  of  pig- 
nient  and  crystals  of  htematoidin  gradually  disappear  in  the  course  of 
months,  leaving  nothing  which  recalls  the  haemorrhage  that  has  oc- 
curred or  the  injury  which  the  tissues  have  suffered.  In  severer  con- 
tusions with  larger,  more  circumscribed  extravasations  of  blood,  the 
extravasation  is  gradually  displaced  by  new-formed  connective  tissue, 
as  in  the  so-called  organisation  of  a  thrombus  in  a  vessel  (see  page  294). 

Organisation  of  the  Extravasated  Blood. — In  contusions  of  perios- 
teum, or  of  bone  or  its  marrow,  the  product  of  the  organisation  is  not 
connective  tissue  but  bone. 

Sometimes  the  organisation  of  the  extravasated  blood  into  connect- 
ive tissue  is  confined  to  the  outer  layers  of  the  extravasation,  as,  for 
example,  in  cerebral  haemorrhages  or  in  haemorrhages  into  the  sub- 
stance of  the  thyroid  gland  or  of  a  tumour.  In  this  way  there  devel- 
ops at  the  point  where  the  extravasation  occurred  a  cyst — that  is,  a 
space  filled  usually  ^^•ith  a  yellowish-red  fluid  and  enclosed  by  a  con- 
nective-tissue capsule.  After  the  licpiid  in  the  cyst  has  been  absorbed 
a  true  connective-tissue  cicatrix  may  eventually  develop. 

Drying,  Calcification,  Suppuration,  and  Gangrene  of  the  Extravasated 
Blood. — In  rare  cases  the  extravasated  blood  becomes  dried,  or  calcare- 
ous concretions  are  formed  by  deposition  of  lime  salts.  The  unfavour- 
able changes  which  the  extravasation  may  undergo  are 'suppuration, 
and  particularly  putrefactive  decomposition  and  gangrene.  These  ter- 
minations are  only  brought  about,  as  mentioned  in  §  57,  by  bacterial 
infection  through  a  cutaneous  injury,  or,  in  rare  instances,  through  the 
circulation,  and  are  seldom  observed  in  subcutaneous  extravasations  of 
blood.  When  infection  does  occur  it  is  usually  due'lo  a  superficial 
cutaneous  injury  orfo  necrosis  of  the  skin  caused  by  the  injury.  It 
is  also  to  be  borne  in  mind  that "TDacteria  may  be  forced  into  the  skin 


504    INJURIES  AND   SURGICAL   DISEASES   OF  THE   SOFT   PARTS. 

when  tlie  latter  is  subjected  to  violence,  and  thej  will  then  find  a 
favourable  medium  for  their  development  in  the  extravasated  blood 
and  the  contused  skin. 

Absorption  of  Extravasated  Lymph. — The  more  or  less  pure  Ijmph 
extravasations  are  ordinarily  ab.^orljed  very  slowly,  and  they  sometimes 
persist  for  months  as  a  soft  fluctuating  tumour;  it  is  an  exceedinijly 
rare  occurrence  for  them  to  undergo  suppuration  or  putrefactive 
change.  The  repair  of  a  wound  and  the  regeneration  of  injured  tis- 
sues are  described  in  ^  61. 

Treatment  of  Contusions. — The  treatment  of  a  contusion  is,  in  the 
first  place,  directed  towards  as  rapid  an  absorption  as  possible  of  the 
extravasation.  A  great  number  of  the  slighter  contusions  get  well 
without  assistance  in  a  comparatively  short  time.  If  a  contusion  of 
soft  parts — on  an  extremity,  for  instance — comes  under  observation 
immediately  after  it  has  been  received,  and  if  a  fracture  has  been  posi- 
tively excluded,  the  injured  extremity  should  be  placed  in  an  elevated 
position  to  diminish  the  pain  and  check  the  subcutaneous  haemorrhage. 
With  the  same  object  in  view  ice  is  employed  locally,  or  cold  applica- 
tions, to  wliich  may  also  be  added  substances  like  acetate  of  lead,  chlo- 
ride of  ammonium,  spirits  of  camphor,  etc.  It  is  always  advantageous 
for  arresting  subcutaneous  haemorrhage  to  apply  a  dressing  which  ex- 
erts a  slight  pressure.  If  the  skin  is  intact  and  there  is  a  considerable 
extravasation  of  blood,  the  latter  should  be  mechanically  forced  into 
the  interstices  of  the  tissues  and  into  the  lymph  channels  by  being 
gently  kneaded  and  rubl)ed  in  a  centripetal  direction  by  the  thumbs, 
fingers,  or  palms.  In  this  manner  the  absorption  of  the  extravasation 
is  hastened.  After  the  massage,  it  is  often  advantageous  to  wrap  the 
injured  portion  of  the  extremity  in  a  flannel,  mull,  or  cotton  bandage 
to  prevent  a  recurrence  of  the  subcutaneous  hsemorrhage  and  swelling. 
As  a  general  thing,  it  is  a  good  plan,  immediately  after  the  massage,  to 
make  the  patient  move  his  contused  muscles  or  joint.  This  increases 
the  effect  of  the  massage  and  materially  hastens  the  absorption  of  the 
extravasation.  Massage  is  suitable  for  subcutaneous  ruptures  and  con- 
tusions like  sprains  of  joints,  which  can  often  be  cured  by  this  method 
within  a  few  days ;  in  fact,  the  effects  of  massage  upon  a  sprain  often 
seem  perfectly  wonderful  to  the  laity.  The  patient  may  have  suffered 
the  severest  kind  of  pain  when  making  the  least  attempt  to  stand  upon 
his  contused  foot  or  ankle,  and  yet  after  massage  has  been  practised 
but  once  he  will  be  able  to  get  about  with  very  slight  pain,  or  practical- 
ly none  at  all. 

The  massage  must  be  repeated  daily,  and  in  the  mott  favourable, 
cases  three  to  five  sittings  will  be  enough  to  effect  a  cure,  while  in 


§92.J  SUBCUTANEOUS  INJURIES  OF  SOFT  PARTS.  505 

others  the  massage  must  be  continued  for  a  longer  time.  The  sooner 
the  massage  can  be  undertaken  after  the  injury  the  more  rapid  will  be 
the  success. 

Technique  of  Massage. — The  technique  of  massage  is  not  as  simple  as  it 
appeai-s.  It  has  recently  been  employed  with  success  for  all  soi'ts  of  troubles. 
Before  begiuuing^  the  treatment  upon  the  injured  portion  of  the  body,  it  is 
very  often  advisable  to  start  with  an  introductory  massage  of  the  healthy 
parts  on  the  proximal  side  of  the  injm-y,  usiug  ceutripetally  directed  strolces 
of  the  hand  to  empty  the  veins  and  lymphatic  vessels  and  thus  promote  the 
absorption  from  the  injured  portion  of  the  bod\\  Massage  of  the  healthy 
parts  on  the  proximal  side  of  the  injury  should  be  emjiloyed  in  all  cases 
wbere  massage  of  the  actually  inflamed  or  injured  portion  of  the  body  is 
impossible  on  account  of  a  cutaneous  injury  or  too  great  pain.  The  parts  to 
be  massaged  and  the  hands  of  the  masseur  should  first  be  smeared  with  lard 
or  vaseline,  to  facilitate  the  strokes  given  by  the  hand. 
■\^^'  There  are  in  general  four  methods  of  employing  massage:  1.  Effleurage, 
or  ceutripetally  directed  strokes  of  varying  strength  made  with  the  palm  of 
the  hand  or  its  radial  border.  2.  Massage  a  friction,  or  vigorous  circular 
rubs  with  the  hand  or  finger  tips,  and  particularly  with  the  thumbs,  to  break 
up  and  scatter  pathological  products.  3.  Petrissage,  or  elevation  of  a  portion 
of  tissue  with  both  hands,  or  with  the  fingers  of  one  hand,  followed  by 
squeezing  and  kneading  the  parts  thus  lifted.  4.  Tajjotement,  or  heatino;  and 
striking  the  part  under  treatment  with  the  hand,  or  with  some  in.strumeut 
made  of  wood,  rubber,  etc.,  specially  constructed  for  the  piu'pose.  The 
length  of  time  occupied  at  each  sitting  varies  greatly;  it  may  be  two  to  three 
minutes,  or  as  much  as  five  to  fifteen  minutes  or  longer,  depending  upon  the 
extent  of  surface  to  be  covered. 

Of  course,  a  great  number  of  contusions  are  not  suited  for  massage. 
In  this  category  belong  all  cases  in  which  the  skin  has  been  severely 
damaged  by  mechanical  violence,  or  where  large  vessels  have  been  rup- 
tured, in  consequence  of  which  considerable  extravasations  of  blood 
have  occurred,  or  where,  in  addition  to  an  extensive  contusion  and 
crushing  of  soft  parts,  there  is  also  a  fracture  of  a  bone.  Every  cuta- 
neous abrasion,  no  matter  how  superficial  it  may  be,  must  be  care- 
fully treated  upon  antiseptic  principles.  The  subcutaneous  extravasa- 
tion of  blood  will  also  be  diminished  by  an  antiseptic  dressing  which 
exerts  pressure.  In  other  cases  there  may  be  a  scab  of  dried  blood 
which  will  protect  the  cutaneous  injury  from  infection.  If  juppura. 
tion  occurs — i.  e.,  if  the  skin  becomes  hot,  red,  and  tender,  and  fluctua- 
tion is  detected — incisions  should  be  made  in  the  most  dependent  parts, 
drainage  inserted,  and  antiseptic  dressings  applied.  Should  putrefac- 
tion of  the  extravasated  blood  set  in — i.  e.,  should  there  be  a  rapid  in- 
crease in  the  size  of  the  inflammatory  tumour,  with  high  fever  and 
chills — vigorous  treatment  must  be  adopted.    Incisions  should  be  made 


506    INJURIES  AND  SURGICAL  DISEASES  OP  THE  SOFT  PARTS. 

as  large  and  numerous  as  j^ossible  in  order  tlmt  the  secretion  from  the 
wound  may  freely  escape.  The  wound  should  then  be  disinfected  with 
a  1  to  1,000  solution  of  bichloride  of  mercury,  or  with  a  three-  to  five- 
per-cent.  solution  of  carbolic  acid,  and  all  gangrenous  shreds  of  tissue 
removed.  Early  amputation  is  sometimes  indicated  wlien  there  are 
extensive  gangrenous  changes,  but,  as  a  rule,  such  interference  is  very 
rarely  called  for.  AVhen  large  extravasations  of  blood  are  absorbed 
very  slowly,  or  at  best  but  incompletely,  it  is  allowable  to  open  them 
up,  scrape  them  out,  and  drain  the  cavity  thus  formed.  This  applies 
especially  to  the  above-mentioned  purely  lymph  extravasations.  They 
neither  coagulate  nor  become  absorbed,  and  are  rather  more  apt  to 
increase  in  size  ;  consequently  the  majority  of  these  cases  should  be 
treated  by  operation.  They  should  be  opened  as  much  as  is  necessary 
by  an  incision  and  scraped  out.  Furthermore,  when  a  large  vessel  is 
ruptured  subcutaneously,  nnless  the  haemorrhage  ceases,  the  vessel  must 
eventually  be  sought  for  at  the  point  of  the  injury  and  ligated  on  the 
proximal  and  distal  side  of  the  injured  spot,  and  the  intervening  con- 
tused portion  of  the  vessel  extirpated.  The  special  treatment  for  con- 
tusions of  joints  and  bones  is  described  in  the  paragraphs  upon  these 
subjects. 

Muscular  paralyses  following  contusions  of  nerves,  if  the  continuity 
of  the  nerve  is  not  interrupted,  usually  disappear  under  electrical  treat- 
ment. If  the  nerve  has  been  completely  divided,  neurorrhaphy  should 
be  performed  in  the  ordinary  way  (see  page  409). 

Sulacutaneous  Rupture  of  Healthy  Muscles  and  Tendons. — The  subcu- 
taneous rupture  of  healthy  muscles  and  tendons  ordinarily  only  occurs 
as  a  result  of  the  action  of  great  force,  such  as  a  violent  muscular  eifort 
or  an  excessive  strain  at  the  time  of  the  dislocation  of  a  joint,  or  from 
direct  violence,  such  as  a  blow,  etc.  As  a  result  of  excessive  muscular 
exertion,  as  in  jumping,  there  may  occur  a  rupture  of  the  gastroc- 
nemius or  of  the  tendo  Achillis.  In  a  similar  manner  there  may  fol- 
low a  rupture  of  the  tendon  of  the  quadriceps  extensor  when  an  indi- 
vidual is  in  danger  of  falling  and  tries  to  hold  himself  on  his  feet  by 
vigorously  contracting  the  extensor  muscles  of  the  leg.  ■  The  ruptures 
may  be  partial  or  complete,  and  occur  either  in  the  muscle  or  the 
tendon.  Purely  muscular  ruptures  are  most  common  in  long-bellied 
muscles  possessing  either  a  very  short  tendon  or  none  at  all,  such  as 
the  rectus  abdominis  or  the  sterno-cleido-mastoid.  Not  infrequently 
tendons  are  torn  from  their  points  of  insertion  with  or  without  a  tear- 
ing away  of  bone  substance  (so-called  torn  fractures).  The  tear  takes 
place  where  there  is  the  least  resistance.  If  muscles  and  tendons  en- 
dure the  increased  amount  of  strain,  their  points  of  insertion,  the  bony 


§92.]  SUBCUTANEOUS  INJURIES  OF  SOFT   PARTS.  50T 

prominences,  may  break  ofT,  and  tlius  there  may  result  transverse  frac- 
tures of  the  patelhi,  or  fractures  of  the  processus  calcanei  posterior,  in 
consequence  of  excessive  strain  from  the  quadriceps  femoris  or  gastroc- 
nemius with  its  tendo  AchilHs. 

Tlie  tearing  away  of  the  muscles  or  tendons  at  their  points  of  in- 
sertion on  tiie  bones,  with  or  without  laceration  of  bone  substance,  is 
particularly  apt  to  occur  in  traumatic  dislocations  of  joints  such  as  the 
shoulder  or  hip. 

Very  rarely  ruptures  of  muscles  or  tendons  are  produced  by  direct 
violence — a  blow  or  a  thrust. 

If  muscles  or  tendons  have  suffered  a  loss  in  their  powers  of  resist- 
ance as  a  result  of  inflammation  or  degenerative  processes,  such  as 
fatty  or  waxy  degeneration  accompanying  constitutional  febrile  dis- 
eases, a  very  moderate  amount  of  mechanical  violence  may  prove  suf- 
ficient to  cause  a  rujJture.  These  ruptures  of  diseased  muscles  and 
tendons  are  called  spontaneous,  in  contradistinction  to  the  ruptures  of 
healthy  muscles  and  tendons. 

The  symptoms  of  subcutaneous  rupture  of  a  tendon  or  muscle — an 
accident  which  is  most  commonly  observed  in  military  practice — consist 
first  of  all  in  the  inability  to  perform  those  movements  of  which  the 
ruptured  muscle  is  ordinarily  capable.  At  the  injured  point  it  is  usu- 
ally evident  that  the  ruptured  ends  of  the  muscles  or  tendons  are  sepa- 
rated by  a  greater  or  less  interval,  and  that  in  this  gap  in  the  tissues 
there  is  a  correspondingly  large  fluctuating  extravasation  of  blood.  If 
the  latter  is  considerable,  it  may  render  the  diagnosis  diflScult.  The 
patients  themselves  often  direct  the  attention  of  the  physician  to  the 
nature  of  their  injury  by  positively  stating  that  they  have  plainly  felt 
or  heard  a  rupture  of  the  tissues. 

The  subcutaneous  muscular  and  tendinous  ruptures  usually  heal 
readily  under  proper  treatment,  without  being  followed  l)y  any  disturb- 
ance whatsoever ;  suppuration  is  scarcely  ever  observed.  Even  when 
no  suitable  treatment  is  adopted,  the  muscular  and  tendinous  stumps 
very  often  heal  together  by  the  formation  of  an  interposed  connective- 
tissue  cicatrix,  such  as  takes  place,  for  example,  after  the  subcutaneous 
division  of  the  tendons  and  muscles  undertaken  for  the  cure  of  club- 
foot or  other  joint  or  muscular  contractures.  The  connective-tissue 
cicatrix  interposed  between  the  muscular  and  tendinous  stumps  is  at 
the  outset  adherent  on  all  sides  to  the  surrounding  parts.  These  ad- 
hesions are  gradually  torn  or  stretched  as  soon  as  the  jDatient  again 
begins  to  use  his  muscles. 

Even  after  loss  of  muscular  substance  such  as  follows  suppuration, 
the  two  stumps  of  the  muscle  can  become  bound  together  by  a  con- 


508    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT  PARTS. 

iiective-tissne  cicatrix,  a  kind  of  inscriptio  tendinea,  and  the  muscle 
be  rendered  capable  of  performing  its  functions. 

It  sometimes  happens  after  subcutaneous  rupture  of  a  tendon  that, 
in  consequence  of  the  retraction  of  the  central  end  of  the  tendon,  the 
two  stumps  do  not  directly  unite  with  one  another  but  with  the  over- 
lying skin.  Both  tendon  stumps  in  such  cases  then  become  adherent 
to  the  skin,  and  the  latter  may  become  so  mobile  that  it  follows  the 
movements  of  the  tendon,  and  the  latter  performs  its  normal  functions. 

After  muscular  ruptures  subsequent  contractures  sometimes  de- 
velop. In  this  class  of  cases  belongs  the  so-called  congenital  form  of 
wry-neck  {caput  obstipiim\  which  is  due  generally  to  a  partial  rupture 
of  the  sterno-mastoid  muscle,  usually  the  result  of  operative  interfer- 
ence during  birth.  According  to  Stromej'er  and  Yolkmann,  the  con- 
tracture is  produced  in  part  by  a  cicatricial  shrinkage  of  the  muscular 
substance,  and  in  part  by  the  oblique  position  of  the  head  instinctively 
assumed  from  the  time  of  birth.  According  to  Petersen,  the  sternomas- 
toid  muscle  involved  in  caput  obstipiim  is  congenitally  shortened.  In 
other  cases  a  contracture  after  muscular  and  tendinous  rupture  is  caused 
by  the  action  of  the  antagonistic  groups.  But  it  is  certain,  as  the  divis- 
ion of  tendons  for  contractures  also  proves,  that  these  so-called  antago- 
nistic muscular  contractures  are  not  b\-any  means  so  severe  nor  so  com- 
mon as  was  formerly  believed  to  be  the  case.  "We  shall  discuss  this  ques- 
tion more  fully  under  the  subject  of  contractures  of  the  hand  and  foot. 

Treatment  of  Subcutaneous  Muscular  and  Tendinous  Ruptures. — This 
consists  essentially  in  approximating  as  closely  as  possible  the  divided 
and  separated  ends  of  the  muscles  and  tendons,  and  preventing  the  use 
of  the  muscles  or  tendons,  whenever  possible,  by  immobilisation  of  the 
affected  portion  of  the  body.  AVherever  it  is  feasible,  an  attempt  should 
be  made,  after  division  of  the  skin  under  antiseptic  precautions,  to 
obtain  primary  union  by  sutures  connecting  the  muscular  or  tendinous 
stumps  (see  Tenorrhaphy). 

Occurrence  of  Subcutaneous  Muscular  and  Tendinous  Ruptures.— Recently 

Maydl.  in  particular,  has  written  a  very  exhaustive  treatise  upon  this  subject, 
and,  by  collectincr  a  great  number  of  cases  of  rupture  of  muscles  and  tendons 
on  the  trunk  and  extremities,  he  has  demonstrated  that  the  injury  is  not  so 
rare  as  was  formerly  believed.  He  has  collected  sixtj'-one  cases  of  rupture 
of  the  quadriceiDS  extensor  muscle  or  of  its  tendon,  and  fifty-seven  cases  of 
ruptui'e  of  the  lig-amentum  patellae.  He  states  that  one  hundred  and  three 
cases  of  rupture  of  the  muscles  of  the  upper  extremity  and  of  the  muscles 
and  tendons  of  the  trunk,  including'  the  muscles  attached  to  tlie  pelvis,  have 
been  published  ;  of  these,  the  most  common  ruptures  were  those  of  the  ster- 
no-cleido-mastoid,  the  rectus  abdominis,  the  biceps  brachii,  the  psoas  and 
biceps  femoris  muscles. 


§92.] 


SUBCUTANEOUS  INJURIES  OF  SOFT   PARTS. 


509 


Fig.  312. — Muscular  hernia  (adductor 
lonjrus)  resulting  from  a  rupture 
of  tlie  fa.scia.  due  to  a  fall  from  a 
horse.    (Kawitz.) 


Muscular  Hernia. — The  protrusion  of  a  portion  of  a  muscle  through 
an  unhealed  ruj)ture  in  its  overlying  fascia  or  sheath  is  called  a  mus- 
cuhir  hernia.  In  cases  of  this  description,  during  the  contraction  of 
the  affected  ihuscle,  a  j^ortion  of  its  belly  pushes  itself  through  the 
gaping  tear  in  the  fascia  or  sheath  of  the  muscle  and  forms  an  elastic 
fluctuating  tumour  (Fig.  312).  Hernias  of  the  straight  abdominal  mus- 
cles and  of  the  muscles  of  the  tliisli  seem 
to  be  the  most  common,  occurring  par- 
ticularly in  the  soldiers  of  cavalry  and 
artillery  regiments.  As  Baudin  has  re- 
cently demonstrated,  the  affection  is  not 
so  rare  as  was  formerly  believed.  In 
the  thigh  the  development  of  muscular 
hernias  after  subcutaneous  rupture  of 
the  fascia  is  favoured  by  the  very  slight 
distensibility  of  the  fascia,  by  its  tense 
arrangement  on  the  inner  side  of  the  leg, 
and  by  a  frequently  repeated,  excessive 
stretching  of  the  adductors  such  as  oc- 
curs in  riding.  The  observations  of  Bau- 
din show  that  a  sudden  rupture  of  the 
fascia  does  not  necessarily  occur.  Much  more  commonly  there  is  a 
gradual  forcing  asunder  and  tearing  apart  of  the  fibres  of  the  fascia. 
On  account  of  the  poor  nerve  supply  in  the  fascia,  a  tear  in  the  latter 
is  not  ordinarily  accompanied  by  pain.  As  regards  the  diagnosis,  it  is 
characteristic  for  tumours  due  to  muscular  hernias  to  disappear  or  be- 
come prominent  as  the  points  of  origin  and  insertion  of  the  affected 
muscle  are  separated  from  or  approximated  to  one  another. 

If  the  discomfort  caused  by  such  a  muscular  hernia  is  considerable, 
an  operation  should  be  undertaken  for  its  cure.  The  skin  is  incised, 
the  ruptured  fascia  exposed,  and  the  edges  of  the  rent  freshened  and 
drawn  together  by  catgut  sutures.  After  healing  is  complete,  an  elas- 
tic dressing  which  exerts  pressure  in  the  form  of  an  elastic  girdle,  pos- 
sibly with  a  flat  pad,  should  be  worn  for  some  time.  In  mild  cases, 
and  when  patients  are  afraid  of  the  knife,  we  are  forced  to  confine 
ourselves  to  a  purely  palliative  treatment  of  the  affection  by  an  elastic 
girdle  with  a  flat  pad. 

Dislocations  of  Muscles  and  Tendons. — Displacements  of  muscles  and 
tendons  after  laceration  of  their  fasciae  and  synovial  sheaths  have  re- 
ceived the  name  of  dislocations.  In  general  they  are  very  rarely  ob- 
served, and  mainly  occur  when  the  muscle  or  tendon  in  question  by 
some  violent  movement  slips  over  a  bony  prominence  where  it  is  held 


510    INJURIES  AND   SURGICAL    DISEASES  OF   THE   SOFT   PARTS. 

fast.  Displacement  of  the  tendons  of  the  peronei  muscles  on  to  the 
outer  surface  of  the  external  malleolus  may  occur  in  severe  sprains 
of  the  ankle  joint.  There  is  a  division  of  opinion  as  to  the  frequency 
with  which  dislocation  of  the  biceps  tendon  occurs  from  the  bicipital 
groove  over  the  lesser  tuberosity  of  the  humerus.  According  to  Cow- 
per,  the  dislocation  is  particularly  apt  to  occur  in  forced  elevation  of 
the  arm,  and  the  accident  is  characterised  by  severe  pain  in  the  region 
of  the  lesser  tuberosity,  and  by  inability  to  move  the  shoulder  joint, 
Jarjavay,  Pitha  and  others  doubt  the  occurrence  of  simple  dislocations 
of  the  biceps  tendon  unaccompanied  by  dislocation  or  fracture  of  the 
upper  end  of  the  humerus. 

The  reposition  of  the  dislocated  tendons — of  the  peronei,  for  ex- 
ample— is  an  easy  matter  in  recent  cases.  To  keep  the  tendons  in 
their  proper  position  after  they  have  been  replaced,  a  suitable  retentive 
dressing  should  be  applied  so  as  to  exert  pressure  upon  tlie  point 
where  the  dislocation  has  occurred,  while  the  joint  is  made  to  assume 
a  suitable  position,  which  in  dislocation  of  the  peronei  consists  in 
supinating  the  foot.  As  dislocations  of  tendons  are  particularly  apt 
to  occur  when  the  bony  grooves  are  not  deep  enough,  and  as  this  con- 
dition also  favours  their  recurrence,  it  is  occasionally  advantageous  to 
make  use  of  Albert's  method,  and  deepen  the  groove  subperiosteally 
with  a  gouge  and  then  reunite  the  elevated  periosteum  by  catgut 
sutures.  Maydl  also  recommends  freshening  and  suturing  together 
the  lacerated  edges  of  the  tendon  sheath.  If  there  is  atrophy  of  the 
tendon  sheath,  a  portion  of  the  periosteum  may  be  turned  over  the  ten- 
don and  sutured  to  its  sheath. 

Dislocations  of  Nerves. — These  occur  under  conditions  similar  to 
those  described  for  dislocations  of  the  tendons  and  muscles.  Disloca- 
tion of  the  ulnar  nerve  from  its  groove  behind  the  internal  condyle 
of  the  humerus  is  a  particularly  familiar  accident.  In  obstinate  cases 
the  bony  groove  should  be  deepened  subperiosteally  M'ith  a  gouge,  or 
the  nerve  should  be  secured  in  position  by  suturing  its  sheath  to  the 
fascia  or  inner  border  of  the  triceps  tendon  and  covering  in  the  nerve 
by  suturing  the  fascia  over  it  to  the  periosteum  (Stabb). 

Subcutaneous  stretching,  tearing,  or  laceration  of  the  capsules  of 
joints  and  their  ligaments — the  so-called  sprains — will  be  discussed 
under  the  subject  of  Injuries  of  Joints  ('§  121). 

§  93.  The  Diseases  of  the  Skin  and  Cellular  Tissue. — The  diseases  of 
the  skin  are  very  numerous,  since  it  is  so  much  exposed  to  injurious 
influences  from  without,  and  since  it  bears  such  an  intimate  relation- 
ship to  the  whole  organism.  This  relationship  to  the  rest  of  the 
system  explains  why  the  skin  presents  secondary  symptomatic  changes 


guaj      THE   DISEASES  OF   THE  SKIN   AND  CELLULAR  TISSUE.       511 

in  diseased  conditions  of  the  nervous  system,  tlie  blood,  tlie  lympliatic 
system,  and  the  internal  organs. 

The  trophoneurotic  cutaneous  affections  are  extremely  interesting. 
We  know  that,  as  a  result  of  long-continued  irritation  of  peripheral 
nerves,  there  may  occur  not  only  degenerative  changes  in  the  periph- 
eral portions  of  these  nerves,  accompanied  by  trophic  disturbances, 
but  that  also  the  peripheral  changes  may  advance  in  the  form  of  an 
ascending  neuritis  to  the  spinal  cord  and  brain.  These  secondary  dis- 
eases of  the  central  nervous  system  may  then  in  turn  give  rise  to 
trophic  disturbances  of  the  skin,  to  inflammation,  gangrene,  ulcers, 
vasomotor  disturbances,  etc.  I  should  also  mention  at  this  place  the 
reflex  angioneuroses,  in  which,  as  a  result  of  various  kinds  of  irritation 
such  as  may  proceed  from  the  sexual  organs,  manifold  polymorphous 
exanthemata  including  wheals,  papular  efllorescences,  erythema  nodosum, 
etc.,  may  occur. 

We  shall  confine  ourselv^es  here  to  only  the  most  important  dis- 
eases of  the  skin  in  so  far  as  they  come  under  the  treatment  of  the 
surgeon. 

Acute  Inflammations  of  the  Skin. — The  principal  acute  inflammations 
of  the  skin  of  interest  to  the  surgeon  are  erythema,  eczema,  furuncle, 
carbuncle,  and  erysipelas ;  the  latter  is  described  in  §  71. 

1.  Erythema. — By  erythema  (dermatitis  erythematosa)  is  understood 
an  acute,  circumscribed  inflammation  mainly  involving  the  papillary 
layer  of  the  skin.  In  consequence  of  the  inflammatory  hj-persemia  the 
skin  is  reddened  and  somewhat  swollen.  The  temperature  of  the  af- 
fected area  is  elevated,  and  there  is  usually  a  sharp,  burning  pain.  The 
anatomical  changes  in  erythema  consist  in  a  serous  exudation  into  the 
space  between  the  most  superflcial  layer  of  the  cutis  and  the  rete  Mal- 
pighii,  and  in  a  more  or  less  pronounced  infiltration  with  leucocytes. 
The  cells  of  the  rete  Malpighii  are  generally  somewhat  enlarged  and 
swollen.  As  a  result  of  the  exudation,  the  epidermis  is  often  elevated 
in  the  form  of  small  blebs  which  are  filled  with  serum  or  pus.  Ery- 
thema usually  terminates  in  a  complete  restitutio  ad  integrum,  without 
leaving  any  visible  cicatrix.  The  epidermis  comes  off  mostlj'  in  the 
form  of  scales  or  large  flakes.  If  the  irritation  continues  \ox\q-  enouo:h, 
small  ulcers  may  occasionally  develop  from  the  blebs,  but  these,  too,  as 
a  rule,  heal  very  rapidly.  The  causes  of  erythema  are  very  varied. 
Ordinarily  the  disease  originates  from  a  local  mechanical,  thermal,  or 
chemical  irritation  ;  it  may  thus  come  from  superficial  burns  or  frost- 
bites, from  continued  irritation  of  the  skin  by  wet  bichloride  or  car- 
bolic dressings,  or  it  may  be  caused  b}'  sweat,  urine,  or  pus,  particularly 
in  localities  where  areas  of  skin  rub  together,  as  at  the  anus,  the  vulva. 


512   INJURIES  AND   SURGICAL   DISEASES   OP  THE   SOFT   PAlJTS. 

in  the  axilla,  or  after  the  ingestion  of  various  kinds  of  food  or  medica- 
ments (quinine),  etc. 

Erythema  Multiforme,  Erythema  Nodosum. — In  endocarditis,  as  a 
result  of  infection  by  micro-organisms,  and  in  all  cases  of  acute  and 
chronic  infectious  diseases,  various  forms  of  erythema  sometimes  oc- 
cur, particularly  erythema  multiforme  and  erythema  nodosum.  The 
etiology  of  erythema  multiforme  is  extremely  varied.  In  addition 
to  the  toxic  influences  which  bacteria  exert,  a  very  important  part  is 
played  by  alterations  in  the  nervous  system,  including  both  the  pe- 
ripheral nerves  and  the  central  nervous  system,  and  by  irritations  of  the 
skin  when  the  nervous  system  is  normal. 

The  Treatment  of  Erythema  consists  in  the  use  of  washings  and 
baths.  For  pure  hyperaimia  ice  and  lead-water  should  be  employed, 
and  the  parts  should  be  covered  with  unguentum  lithargyri  Hebrae 
(unguentum  diachylon),  or  vaseline,  and  afterwards  dusted  with  starch 
or  oxide  of  zinc  and  starch  (1  to  5  to  10),  and  then  covered  with  cot- 
ton. The  latter  treatment  is  particularly  good  when  blebs  are  present ; 
they  rapidly  disappear  under  the  application  of  desiccating  substances 
such  as  unguentum  diachylon  or  vaseline,  or  when  dusted  with  starch 
and  zinc  oxide.  But  the  cause  of  the  erythema  should  ahvays  be  taken 
into  account,  especiallj'  if  it  is  a  bacterial  erythema — i.  e.,  an  erythema 
occurring  in  the  course  of  an  infectious  disease. 

2.  Eczema. — Amongst  the  inflammations  of  the  skin  in  Mdiicli  there 
is  a  formation  of  blebs  -special  mention  should  be  made  of  eczema, 
which  is  sometimes  acute  and  sometimes  chronic,  and  consists  in  the 
development  of  papules,  vesicles,  and  pustules  which  dry  and  form 
crusts.  The  skin  in  the  neighbourhood  of  the  vesicles  is  usually  more 
or  less  inflamed.  Eczema,  too,  is  particularly  apt  to  be  excited  by  all 
sorts  of  external  irritation,  such  as  wet  antiseptic  dressings  of  bichlo- 
ride, carbolic  acid,  etc,  A  large  number  of  very  different  skin  diseases 
are  included  etiologically  under  the  term  eczema  which  should  really 
be  separated. 

An  important  tyjie  of  eczema  is  the  eczema  sehorrhoicum,  in  which 
there  is  a  formation  of  scales  and  crusts  on  those  parts  of  the  body 
which  are  richly  supplied  with  sebaceous  glands,  such  as  the  hairy  por- 
tion of  the  scalp,  the  edges  of  the  eyelid,  the  axilla,  etc.  (Unna). 

Treatment  of  Eczema. — The  treatment  of  acute  eczema  consists  in 
removing  the  cause,  such  as  the  wet  dressings,  and  then  in  the  apjilica- 
tion  of  desiccating  remedies — unguentum  diachylon  or  vaseline,  dusting 
with  zinc  oxide  and  starch,  and  covering  with  cotton,  but  without  gutta 
percha  over  it,  since  the  drier  the  eczematons  area  is  ke])t  the  better. 
If  success  is  not  obtained  by  these  methods,  a  trial  should  be  made 


§93.]      THE  .  ;^EASES   OF  THE  SKIN    AND   CELLULAR  TISSUE.        513 

witli  zinc  glue  (oxide  of  zinc  and  gelatine,  each  one  part,  glycerine  and 
aq.  destil.,  each  four  parts),  Unna's  ointment  of  benzoate  of  zinc  spread 
on  ganze,  Pick's  salicylic-soap  plaster,  Lassar's  zinc  paste,  etc.  Chronic 
eczema  is  treated  in  essentially  the  same  way.  In  addition  we  use 
animal  ])re])arations — ichthyul  (internally  and  externally),  liniments 
which  are  allowed  to  dry  on,  etc.  Pick's  bichloride  gelatine,  the  sali- 
cylic-soap plaster,  Lassar's  salicylic  paste,  Unna's  salicylic-])laster  mull, 
two  to  ten  per  cent,  of  chrysarobin  or  pyrogallic  acid  in  vaseline,  are 
all  useful  preparations.  Arsenic  should  be  administered  internally, 
and  in  children  oftentimes  cod-liver  oil.  Any  constitutional  dyscrasiae, 
such  as  gout,  diabetes,  scrofula,  etc.,  should  receive  special  treatment. 
The  diet  should  be  carefully  regulated. 

Other  Skin  Diseases. — According  to  the  different  forms  and  causes  of 
erytheina  and  the  skin  inflammations  in  which  blebs  develop,  many  vari- 
eties of  these  diseases  are  distinguished,  such  as  erythema  esudativum  multi- 
forme, erythema  nodosum,  urticaria  tuberosa,  impetigo  (pustules  drying  and 
forming  crusts),  etc.  We  cannot  discuss  at  this  place  other  cutaneous  affec- 
tions like  psoriasis  (development  of  dry,  white  scales),  prurigo  (inflammation 
accompanied  by  the  formation  of  papules),  and  the  various  manifestations  of 
syphilis.  By  miharia  is  understood  an  eruption  of  small,  transparent  vesicles; 
by  herpes,  vesicles  arranged  in  groups— for  instance,  upon  the  lips  (herpes 
labialis)  or  prepuce-  (herpes  preputialis),  and  on  the  back  (herpes  zoster). 
Herpes  zoster  occurs  along  the  distribution  of  some  particular  nerve,  and  is 
sometimes  present  when  changes  have  taken  place  in  the  spinal  ganglia  and 
the  Gasserian  ganglion.  The  infectious  character  of  herpes  zoster  is  becom- 
ing more  and  more  insisted  upon ;  epidemics  of  this  affection  have  repeatedly 
been  observed  (Pick,  Kaposi).  By  pemphigus  is  understood  a  cutaneous 
eruption  with  the  formation  of  blebs  which  vary  in  size  from  that  of  a  pea  to 
that  of  a  hen's  or  goose's  egg. 

All  moist  cutaneous  affections  accompanied  by  the  formation  of 
blebs  are  best  treated  in  the  manner  described  above  for  eczema — viz., 
by  desiccating  dressings  with  oxide  of  zinc,  or  ointment  dressings,  such 
as  unguentum  diachylon. 

3.  The  Furuncle. — By  a  furuncle  is  understood  an  acute  inflamma- 
tion of  the  sebaceous  glands  and  hair  follicles,  which  is  always  due  to 
micro-organisms,  especially  the  staphylococcus  pyogenes  aureus  and 
albus  (Garre).  By  the  penetratioii  of  the  micro-organisms  into  the 
mouths  of  the  sebaceous  glands  there  is  first  developed  a  pustule  (acne) 
about  the  size  of  a  pin-head,  which  soon  enlarges  into  a  very  painful 
nodule  the  size  of  a  pea  or  bean.  After  a  few  days  suppurative  sof- 
tening usually  develops  in  the  centre  of  the  nodule.  Occasionally  the 
Inflammation  extends  more  deeply  and  spreads  into  the  surrounding 
parts,  giving  rise  to  a  cellulitis  with  extensive  suppuration  or  necro- 
33 


514    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOF,'''  PARTS. 

sis  of  the  underlying  fascia.  Many  people  are  very  subject  to  furun- 
cles. They  sometimes  develop  simultaneously  in  various  parts  of  the 
body  in  individuals  who  are  otherwise  perfectly  healthy ;  the  same 
thing  also  happens  in  diabetes,  during  the  convalescence  from  typhoid 
fever,  etc.  It  is  interesting  to  note  that  dui-ing  the  furuncnlosis  occur- 
ring in  perfectly  healthy  people,  sugar  sometimes  appears  in  the  urine 
and  vanishes  after  the  recovery  from  the  furuncnlosis.  In  hospitals 
where  the  antisepsis  is  defective  furuncle  epidemics  sometimes  arise. 

Treatment  of  a  Funmcle. — The  best  treatment  of  a  furuncle  is  early 
incision  under  local  angesthesia  with  cocaine  and  the  ether  spray,  to 
alleviate  the  painful  tension  and  to  provide  an  escape  for  the  pus. 
Very  often  it  is  possible  to  prevent  a  furuncle  from  developing  by 
opening  the  small  acne  pustule  as  soon  as  it  forms  and  disinfecting  it 
with  a  one-tenth-per-cent.  solution  of  bichloride  of  mercury.  In  large, 
fully  developed  furuncles  a  cruciform  incision  should  be  made  and  the 
purulent  masses  carefully  scraped  out.  Ointment  dressings  of  boric- 
acid  ointment  or  vaseline  with  iodoform  are  better  than  dry  dressings. 
Much  time  used  to  be  lost  in  the  treatment  of  furuncnlosis  by  a  purely 
symptomatic  procedure,  such  as  the  employment  of  ice  and  warm, 
moist  applications.  When  there  is  an  extensive  infiltration  of  the 
parts  surrounding  the  furuncle,  the  moist,  warm  applications  are  no 
doubt  serviceable ;  but  the  main  point  is  always  to  lessen  the  tension 
])y  an  incision  at  the  earliest  possible  moment,  and  to  provide  a  means 
of  escape  for  the  pus,  in  order  to  prevent  the  development  of  a  cellu- 
litis with  extensive  necrosis  of  tissue.  Bidder  has  recommended  as  an 
abortive  treatment  for  furuncles  the  parenchymatous  injection  of  three 
per  cent,  carbolic  acid. 

The  treatment  for  general  furuncnlosis  consists  in  the  use  of  luke- 
warm baths,  in  regulating  the  diet,  and  in  the  internal  administration 
of  arsenic.  The  local  treatment  is  in  general  the  same  as  that  given 
above.  In jHab^tes,  regulation  of  the  diet  is  particularly  imjDortant 
(meat,  wine).  It  is  well  known  that  in  diabetes  extensive  gangrenous 
processes  sometimes  occur  in  conjunction  with  a  furuncle ;  in  this  con- 
dition the  knife  should  be  used  with  caution. 

4.  Carbuncle. — By  carbuncle  is  understood  a  collection  of  furuncles 
lying  close  together,  giving  the  skin  the  appearance  of  being  perfo- 
rated like  a  sieve  by  separate  foci  of  inflammation.  In  this  condition 
we  generally  have  to  do  with  infection  by  tlie^staphylococcus  pyogenes 
aureus  and  albus.  The  carbuncle  has  a  more^  pronounced  tendency 
than  the  furuncle  to  extend  peripherally.  It  oc_curs  particularly  on 
the  neck,  back,  buttocks,  cheeks  and  lips.  The  carbunclejnjiealthy 
people,  as  a  general  thing,  is  not  dangerous ;  but  it  can  become  com- 


§93.]      TllH    DISEASES  OF  THE   SKIN    AND   CELLULAR   TISSUE.        515 

plicated  with  extensive  phlegmonous  suppuration  and  necrosis  of  the 
skin  and  deeper  tissues,  with  venous  thromboses,  and  n2ajj:erminate 
fatally  from  septictvmia  or  ])ya3mia.  In  a  carhuncje  invjplving  the  lips, 
cheeks,  or  neck,  there  is  reason  for  fearing  an  extension  of  the  inflam- 
mation to  the  cranial  cavity,  as  cases  in  which  this  happens  often  run  a 
rapidly  fatal  course.  AVhen  the  patient  has  diabetes  the  gangrenous 
destruction  of  tissue  is  often  very  considerable,  and  not  infrequently, 
as  a  result  of  the  extensive  gangrene,  and  in  sj)ite  of  energetic  and  suit- 
able local  surgical  treatment,  death  will  occur  from  sepsis  or  pyaemia. 

The  Treatment  of  a  Carbuncle  is  essentially  the  same  as  for  a  fu- 
runcle, and  the  incisions  should  be  made  as  early  as  possible.  Their 
number  will  depend  upon  the  extent  of  the  inflammation,  though  in 
small  carbuncles  it  is  sufficient  to  make  one  longitudinal  or  cruciform 
incision  down  to  healthy  tissue.  If  the  suppuration  and  necrosis  of 
the  tissues  are  sufficiently  far  advanced,  I  remove  the  softened_^an- 
grenous  and  suppurating  parts  with  a  sharp  spoon,  scissors,  and  for- 
ceps, and  disinfect  the  focus  most  carefully  with  a  one-tenth-per-cent.  -^  V<> 
solution  of  bichloride  of  mercury.  For  dressings  I  prefer  iodoform, 
dermatol,  or  zinc  oxide  with  boric  ointment  or  vaseline.  Moist  warm 
applications  are  excellent  for  softening  areas  containing  an  inflam- 
matory infiltration.  Later  on  we  should  always  be  on  the  alert  to  pre- 
vent any  burrowing  of  pus,  any  retention  of  the  discharges,  etc.  Ac- 
cording to  the  extent  of  the  inflammation,  the  antiseptic  dressing 
should  be  changed  once  or  twice  a  day,  or  every  two  to  three  days. 
This  energetic  o^peratiye, treatment  of  a  carbuncle  is  better  thanJlie_old- 
fashioned  symptomatic  method,  which  avoided  the  use  of  the  knife. 
The  strength  of  old  people,  in  particular,  should  be  sustained  by  nu- 
tritious food,  by  wine,  etc.  Cutaneous  defects — loss  of  skin  substance 
on  the  face,  for  example — should  be  remedied  by  plastic  operations. 

The  anthrax  carbuncle  {pustnla  maligna)  is  described  in  §  T7,  and 
acute  inflammation  of  the  skin  and  cellular  tissue  (Cellulitis)  in  ^  70. 

5.  The  Chronic  Inflammations  of  the  Skin  and  Subcutaneous  Cellular 
Tissue — Lupus. — Of  the  chronic  inflammations  of  the  skin  I  shall  first 
take  up  lupus,  a  disease  which  is  to  be  regarded,  in  the  main,  as  a 
tuberculosis  of  the  skin  (see  §  83).  As  a  proof  of  this,  tubercle  bacilli 
are  found  in  the  lupus  foci  (see  page  408).  By  the  inoculation  of  lup- 
ous tissue  into  the  peritonaeum  or  the  anterior  chamber  of  the  eye 
of  guinea-pigs  and  rabbits  unquestionable  typical  tuberculosis  is  pro- 
duced. As  regards  the  pathological  changes  in  lupus,  I  must  refer 
the  reader  to  the  detailed  description  of  tuberculosis  in  §  83 ;  we  shall 
discuss  here  only  the  following  clinical  aspects  of  the  disease.  Lupus 
is  particularly  apt  to   occur  on  the  face,  though  it  also  appears  on 


516    INJURIES  AND   SURGICAL  DISEASES  OF  THE   SOFT   PARTS. 


other  portions  of  the  body,  such  as  the  extremities.  Lupus  originates 
by  the  tubercle  bacilli  finding  lodgement  in  the  normal  pores  of 
the  skin,  or  in  some  wound  which  may  be  a  very  small  cutaneous  in- 
jury or  an  abrasion,  Xot  infrequently  it  may  be  proved  to  have 
originated  by  inoculation  or  by  contact  with  people  having  tubercu- 
losis. This  lupus  coming  from  inoculation,  as  a  result  of  a  direct  in- 
fection, and  occurring  in  individuals  otherwise  perfectly  healthy,  I 
believe  to  be  much  more  common  than  has  hitherto  been  supposed. 
In  lupus  of  the  skin  the  pathological  changes  consist  in  the  formation 
of  small  nodules  made  up  of  typical  tubercles.  The  nodules  may  dis- 
appear by  absorption,  or  break  down  and  supjnirate.  giving  rise  to  cor- 
responding losses  of  substance  in  the  skin — i.  e.,  ulcers.  In  combina- 
tion with  the  nodules  and  ulcers  a  diffuse  infiltration  and  hyperplasia 

of  the  tissues  is  frequently  observed. 
The  epithelium  often  proliferates  in 
an  atypical  form  growing  into  the  sub- 
cutaneous cellular  tissue  and  giving 
rise  to  formations  similar  to  carcino- 
ma. 

As  regards  further  pathological 
changes  in  lupus,  I  must  refer  the 
reader,  as  I  have  before  remarked,  to 
the  detailed  description  of  tuberculo- 
sis in  §  83,  We  shall  confine  our- 
selves here  to  its  clinical  and  thera- 
peutic aspects. 

Clinically,  three  forms  are  distin- 
guished :  lupus  maculosus  (or  lupus 
exfoliativus),  lupus  exulcerans,  and 
lupus  hypertrophicus.  In  lupus  maculosus^  red  or  yellowish-brown 
smooth  spots  are  formed,  with  a  cracked,  exfoliating,  epidermic  cov- 
ering (lupus  exfoliativus).  If  there  is  destruction  of  tissue,  corre- 
sponding ulcers  result,  generally  covered  with  crusts  (lupus  exulce- 
rans), which  may  lead  to  extensive  destruction  of  the  skin  and  adjoin- 
ing parts,  especially  upon  the  nose,  cheeks,  lips,  etc.  (Fig.  313).  Very 
often  the  process  extends  at  the  peripheral  portion  of  the  diseased 
area,  while  in  the  centre  a  smooth  or  seamed  cicatricial  tissue  develops. 
In  lupus  exulcerans  there  will  be  found,  in  addition  to  the  tubercle 
bacilli,  pus  cocci,  especially  the  staphylococcus  pyogenes  aureus.  Ac- 
cording to  Leloir  and  Tavernier,  the  ulcerative  changes  occurring  in 
lupus  are  mainly  due  to  the  pus  cocci  which  come  from  without.  Ca- 
zin  describes  hyaline  flakes  in  the  connective  tissue  of  ulcerating  lupus. 


Fig.  313. — Lupus  of  the  face  i  Esinareli 


g98.J      THE   DISEASES  OF  THE  SKIN   AND  CELLULAR  TISSUE.        517 


Fig.  314. 


Lupus  hypertrophicus  of  the   hand 
^Bu^>ch;. 


They  take  on  a  deep  stain,  with  crystal  violet  (according  to  Kiihne), 
and  are  t;iniilur  to  the  bodies  found  by  Kussel  in  epithelioniata.  The 
nodular  form  uf  lupus  is  called  lupus  hypertrophicus  (Fig,  314).  Be- 
tween these  ditferent  classes  there  are  numerous  transition  forms, 
which  often  occur  close  beside 
one  another  in  the  same  lupous 
collection.  The  clinical  course  of 
lupus  is  usually  very  chronic.  It 
generally  begins  in  children  from 
four  to  twelve  years  of  age,  or 
later,  and  often  lasts  for  many 
years.  In  consequence  of  the 
losses  of  substance  and  marked 
cicatricial  shrinkage  or  diiiuse  cic- 
atricial thickening,  bad  deformi- 
ties result,  particularly  on  the  face 
(Fig.  315,)  the  treatment  of  which 
will  be  discussed  in  the  Special 
Surgery.  Xot  infrequently  pa- 
tients with  lupus  die  of  tuberculosis  of  the  internal  organs — of  the 
lungs,  for  example.  Sometimes  epithelioniata  originate  in  lupous  foci 
and  cicatrices. 

Treatment  of  Lupus. — The  treatment  of  lupus  consists,  in  addition 
to  a  suitably  invigorating  mode  of  life  (see  ,^  S3,  Tuberculosis),  mainly 
in  adopting  energetic  local  surgical 
measures,  such  as  excision  of  the  lupous 
disease  or  its  destruction  with  the  sharp 
spoon  (Yolkmann,  page  72),  the  Paque- 
lin  thermo-cautery  (see  page  74),  or  the 
galvano-cautery  (see  page  76).  The 
earlier  a  lupus  is  removed  by  extirpa- 
tion with  the  knife  the  sooner  may  per- 
manent recovery  be  expected.  The 
wound  from  the  excision  is  either  sim- 
ply closed  by  sutures,  or.  if  this  is  im- 
possible on  account  of  too  great  a  loss 
of  substance,  the  cutaneous  defect  is 
remedied  by  plastic  operations  (see  page  134),  or  by  Thiersch  skin 
grafts  (.see  page  141).  The  plastic  operation  or  transplantation  of 
skin  prevents  the  troublesome  consequences  produced  by  cicatricial 
contraction,  and  is  especially  valuable  in  preventing  recurrences.  By 
excision  of  the  lupus  and  making  use  of  Thiersch  skin  grafts,  particu- 


.-■^ 


Fig.  3ir>.— Lupus  (Esmarch). 


518    INJURIES  AND  SURGICAL   DISEASES   OP  THE   SOFT   PARTS. 

larly  on  the  face,  I  Lave  obtained  very  satisfactory  results  and  have 
prevented  or  overcome  bad  deformities.  Punctures  made  with  a  gal- 
vano-cautery  curved  at  the  end,  or  with  the  fine  tip  of  the  Paquelin 
cautery,  are  exceedingly  serviceable  for  the  pure  macular  or  exfoliating 
lupus,  such  as  occurs  upon  the  face.  We  destroy  lupus  exulcerans  or 
hypertrophicus  by  vigorous  scraping  with  the  sharp  S])oon.  or  by  using 
the  Paquelin  thermo-cautery,  in  case  excision  is  impossible.  I  have 
given  up  the  use  of  caustics  altogether  (caustic  potash,  copper  sulphate, 
nitric  or  chromic  acid,  etc.).  Liebreich  recommends  the  subcutaneous 
injection  of  cantharidic  acid  or  of  the  cantharidate  of  potassium.  It  is 
my  opinion  that  the  treatment  of  lupus  by  ointments  is  entirely  with- 
out effect.  The  constitutional  treatment  by  strengthening  food,  good 
air,  sea  baths,  proper  climate,  etc.,  is,  next  to  the  energetic  local  treat- 
ment, of  the  greatest  importance,  especially  for  preventing  any  recur- 
rence of  the  disease.  The  treatment  of  lupus  by  Koch's  tuberculin  is 
described  on  page  421.  Actual  cures  by  tuberculin  are  rarely  ob- 
tained ;  I  have  never  seen  one.  In  the  course  of  the  treatment,  after 
apparent  improvement  has  occurred  in  the  affected  portion  of  skin,  I 
have  excised  a  piece  of  the  latter  and  found  in  the  deeper  parts, 
under  the  healed  external  cutaneous  covering,  eruptions  of  new  tu- 
bercles. 

6.  TTIcers  of  the  Skin. — By  ulceration  is  understood  a  granulating 
defect  in  the  skin  accompanied  by  a  suppurative  breaking  down  of  the 
granulations,  which  shows  no  tendency  to  heal.  Ulcers  present  great 
differences  as  regards  their  size,  character,  and  course.  The  causes  of 
an  ulcer,  its  location,  and  the  general  condition  of  the  patient,  have  a 
most  important  bearing  upon  its  clinical  course.  According  to  the 
intensity  of  the  reactive  intlammation,  we  make  a  distinction  between 
atonic  or  torpid  ulcers  and  inflammatory  ulcers.  There  are  great  dif- 
ferences in  the  shapes  of  ulcers,  some  being  round,  others  half-moon 
shaped,  circular,  or  irregular  in  outline.  The  surface  of  an  ulcer 
may  be  smooth  or  sunken,  or  more  or  less  prominent.  Accoi-diug  to 
the  character  of  the  surface  of  the  ulcer  or  its  base  we  distinguish 
oedematous,  hemorrhagic,  gangrenous,  sloughing,  and  fungous  ulcers; 
the  latter  are  marked  by  prominent,  spongy,  inflanied  granulations. 
Very  often  a  canal,  or  fistula,  as  it  is  called,  extends  from  the  ulcer  to 
a  greater  or  less  depth  into  the  adjoining  parts.  The  fistulse  (from 
fistula,  a  pipe),  as  a  general  thing,  originate  from  some  deeply  placed 
focus  of  inflannnation  which  has  gradually  made  its  way  to  the  surface. 
The  edges  of  an  ulcer  may  be  either  more  or  less  normal,  flat  or  swoll- 
en, or  hard  and  like  a'  wall  (callous  ulcer),  or  undermined  (sinuous 
ulcer).     Phagedenic  ulcers  ((payeBaiva,  from  ^ayelv,  to  eat)  are  those 


ids.]      THE    DISEASES  OF  THE  SKIN    AND   CELLULAR  TISSUE.        519 


wliicli  increase  more  or  less  rapidly  ifi  circumference  analogously  to 
the  hospital  gangrene  of  wounds  (see  §  72). 

The  causes  of  ulcers  are  very  numerous,  and  are  sometimes  local 
and  sometimes  constitutional.  Ulcers  originate  from  traumatisms  of 
various  descriptions,  from  stasis,  or  from  the  su])purative  breaking 
{fown  of  tumours  and  products  of  inflammation,  such  as  syphilis  (§  84), 
tuberculosis  (§  83),  lupus  and  leprosy 
(§  85).  The  varicose  ulcer  of  the  leg, 
of  so  common  occurrence,  develops  from 
inflannnatory  stasis  in  the  leg  in  con- 
junction with  dilated  veins  (varices,  Fig. 
316).  When  varices  exist,  any  mild  in- 
flammation, a  slight  traumatism,  or  an 
eczema  vesicle  may,  as  a  result  of  tlie 
venous  stasis,  give  rise  to  an  ulcer,  since 
repair  or  the  formation  of  normal  gran- 
ulation tissue  is  rendered  difficult  by  the 
disturbance  in  the  circulation.  Ulcers 
may  also  originate  when  in  any  portion 
of  the  body  a  necrosis  of  the  skin  is 
brought  about  by  pressure.  In  this  class 
belong  the  bedsores  which  occur  upon 
the  sacrum,  over  the  trochanters,  on  the 
heel,  etc.,  in  individuals  whose  nutrition 
is  impaired  and  whose  circulation,  as  a 
result  of  anaemia  and  cardiac  weakness, 
is  imperfect.  Trophoneurotic  gangrene 
and  ulcerative  processes  occur  in  paralyt- 
ic conditions  and  other  diseases  of  the  nervous  system.  Great  interest 
attaches  to  the  often  multiple,  neurotic  ulcers  of  the  skin  occurring  in 
conjunction  with  gangrene  of  the  skin,  as  a  result  of  ascending  neuritis 
wuth  secondary  disease  of  certain  central  portions  of  the  spinal  cord 
(Dontrelepont,  Kopp,  and  others).  The  soft  and  hard  chancres  have 
been  mentioned  in  §  84. 

Treatment  of  TTlcers. — The  treatment  of  ulcers  varies  with  their 
cause.  The  latter  must  always  be  carefully  taken  into  account  if  an 
ulcer  is  to  be  properly  treated  ;  for  example,  a  constitutional  dyscrasia, 
like  syphilis,  tuberculosis,  or  bad  nutrition,  nervous  diseases,  etc.,  must 
at  the  same  time  be  attended  to.  The  treatment  of  every  ulcer  should 
be  conducted  upon  antiseptic  principles.  Dressings  with  iodoform, 
dermatol,  oxide  of  zinc,  bismuth,  naphthaline,  with  or  without  oint- 
ments (boric-acid  ointment),  are  excellent.     The  numerous  antiseptic 


Fig.  31C.  — Vai  n  n-f  til(  ci  of  tlic  leg  (//), 
resultiiiiT  tioiii  \ciiii.0!5e  \eiiis. 


520    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT   PARTS. 

materials  for  covering  a  wound  (powder,  ointments,  etc.)  are  enumer- 
ated in  §§  45,  -16.     Gangrenous  phagedenic  ulcers  are  best  treated  by 
scraping  them  with  a  sharp  spoon,  by  cauterisation  with  caustic  potash, 
the  Paquelin  or  galvanocautery.     In  large  ulcers  the  use  of  perma- 
nent irrigation  (page  ITS),  or  a  bath  for  the  entire  body  (page  179),  are 
sometimes  advantageous.     It  is  very  important  to  prevent  any  stasis, 
any  disturbance  of  circulation,  by  placing  the  parts  in  a  suitable  posi- 
tion, by  rest,  etc.     For  varicose  ulcers  of  the  leg,  satisfactory  results 
are  often  obtained  by  enveloping  the  leg  in  Martin's  elastic  bandage, 
which  possesses  the  great  advantages  of  not  confining  the  patient  to  bed 
and  of  allowing  him  to  attend  to  his  business.     Kot  infrequently,  how- 
ever, Martin's  elastic  bandage  is  not  well  borne,  as  it  excites  a  per- 
sistent eczema,  which  should  be  treated  as  described  on  page  512.     If 
the  borders  of  the  ulcer  are  slightly  movable,  circumcision  of  the  ulcer 
is  an  excellent  means  of  making  it  possible  for  the  base  of  the  ulcer  to 
contract,  thus  hastening  the  healing  (Xussbaum).     The  circumcision  is 
performed  by  carrying  an  incision  through  the  skin  down  to  the  fascia, 
around  the  ulcer  some  one  to  two  to  three  centimetres  from  its  edge. 
For  hastening  the  growth  of  skin  over  the  ulcer.  Thiersch's  method  of 
skin  grafting  (§  42)  is  particularly  serviceable  after  previously  freshen- 
ing or  scraping  off  the  base  of  the  ulcer  with  a  sharp  spoon.     Circum- 
cision of  the  ulcer  can  be  combined  to  good  advantage  with  skin  graft- 
ing.    The  latter  procedure  has  taken  the  place  of  the  implantation  of 
skin  flaps  with  pedicles  taken  from  immediately  adjoining  or  distant 
portions  of  the  body,  and  which  were  formerly  much  in  vogue.     Maas 
in  particular  has  obtained  good  results  from  the  implantation  of  pedun- 
culated skin  flaps  taken  from  a  distant  portion  of  the  body.     He  recom- 
mends that  the  flap  to  be  transplanted  be  cut  as  much  as  possible  in  the 
direction  of  the  course  of  the  vessels,  and,  after  previously  removing 
tlie   layer    of   granulations    in    the   defect  with    a   sharp   spoon,   the 
edges  of  the  ulcer  should  be  freshened  all  around  ;  the  flap  is  then 
united  by  sutures  to  the  borders  of  the  defect  and  by  buried  sutures  to 
its  surface.     The  wounded  and  exposed   portion  of  the  flap  is  pre- 
vented from  drying  hy  ])eing  covered  with  a  plentiful  amount  of  boric- 
acid  ointment  spread  on  gauze.     An  antiseptic  dressing  is  placed  over 
everything,  and  the  portions  of  the  body  under  treatment  are  com- 
pletely immobilised  by  a  plaster-of-Paris  dressing.    Whenever  possible, 
the  dressino;  is  left  undisturbed  for  fourteen  davs  and  then  the  pedicle 
of  the  flap  is  divided.     In  this  way  a  flap  can  be  transplanted  from  the 
breast  to  the  arm,  from  one  leg  to  the  other,  and  from  the  upper  ex- 
tremity to  the  face,  and  joints  can  thus  be  made  moval)]e  which  were 
previously  stiffened  by  cicatricial  contractures — i.  e.  had  lost  their  func- 


§03.]      THE   DISEASES  OP  THE  SKIN   AND   CELLULAR  TISSUE.       521 

tion.  Ill  conclusion,  I  should  mention  that  liypertrophic  bone  under 
the  base  of  an  nicer — in  the  tibia,  for  exainph; — must  be  carefully  lev- 
elled off  with  the  chisel  ;  any  undermined  borders  around  an  ulcer 
should  be  excised,  tistuliB  should  be  laid  open,  etc.  In  many  cases  of 
extensive  ulceration,  when  repair  is  impossible  or  the  affected  limb  is 
useless,  amputation  may  be  indicated.  It  should  be  borne  in  mind  that, 
as  a  result  of  the  exposure  and  erosion  of  a  vessel  by  an  ulcer,  a  serious 
or  even  fatal  luemorrhage  may  occur,  unless  aid  can  be  speedily  obtained. 

Scurvy  (Scorbutus)  and  the  Ulcers  which  occur  with  it.— Ulcers  also  occur 
in  scurvy,  especially  on  the  g-ums,  in  the  upper  portion  of  the  cavity  of  the 
mouth,  and  ou  the  lips.  The  gums  swell  as  a  result  of  haemorrhages,  become 
bluish  red,  and  then  break  down  into  peculiar  bluish-red  ulcers  with  bluish- 
green  borders  and  granulations,  which  bleed  easily.  In  other  respects  scurvy 
is  characterised  by  haemorrhages  into  the  skin  and  the  subcutaneous  cellular 
tissue  (purpura  scorbutica),  into  the  muscles,  joints,  and  from  the  intestine, 
by  general  emaciation,  anaemia,  and  hydraemia.  Scorbutus  now  occurs  less 
often  than  formerly.  It  is  to  be  regarded  essentially  as  a  severe  cachexia,  or 
a  general  disturbance  of  nutrition,  involving  particularly  the  walls  of  the 
blood-vessels.  Whether  micro-organisms  play  any  part  in  the  origin  of 
scurvy  is  still  a  matter  of  uncertainty.  The  disease  occurs  endemically, 
especially  among  individuals  who  live  under  unfavourable  external  condi- 
tions, such  as  sailors  who  have  eaten  for  a  long  time  only  salted  meat  without 
any  fresh  vegetable  food.  It  also  occurs  in  danip,  badly  ventilated  and 
crowded  quarters  (prisons,  barracks,  etc.).  Scorbutus  has  only  a  slight  in- 
terest for  the  surgeon,  so  that  we  must  refer  the  reader  to  the  text-books  on 
internal  medicine.  The  prognosis  of  this  affection,  which  for  the  most  part 
runs  a  chronic  course,  depends  upon  the  possibility  of  speedily  removing  the 
unfavourable  hygienic  conditions.  Hence  the  treatment  consists  mainly  in 
providing  good  dwellings  and  good  food  (fresh  meat,  fresh  vegetables).  In 
addition  to  this,  acids — particularly  vegetable  acids — are  beneficial  in  the 
form  of  fresh  watercress  and  sorrel.  Since  legislation  has  provided  that 
ships,  prisons,  etc.,  should  be  well  supplied  with  food,  and  that  the  inmates 
of  prisons  obtain  fresh  vegetables  in  sufficient  quantity,  scurvy  has  become 
less  common.  The  ulcers  in  the  mouth  should  be  treated  by  mild  cautei'isa- 
tion  with  nitrate  of  silver,  iodoform,  and  gargles  of  three-per-cent.  chlorate 
of  potash  or  boric  acid. 

Other  Anomalies  of  Granulating  Wounds.— In  addition  to  the  ulcerative 
destruction  of  granulations  there  are  still  other  anomalies  of  granulating 
wounds  which  interfere  with  their  healing,  and  these  we  shall  discuss  briefly. 
By  fungous  or  spongy  granulations  are  understood  those  which  project  above 
the  level  of  the  surface  of  the  wound  in  the  form  of  a  fungus.  Soft,  luxu- 
riant granulations  like  these  are  observed  in  tuberculosis  especially,  and  also 
when  there  are  anj^  hindrances  to  healing,  such  as  those  due  to  induration  of 
the  surrounding  parts,  or  to  the  presence  of  a  foreign  body,  or  a  necrotic 
piece  of  bone — a  sequestrum,  as  it  is  called — in  the  depths  of  the  wound.  The 
treatment  of  these  fungous  granulations  consists  in  removing  the  above- 
mentioned  causes  and  in  applying  energetic  cauterisation  with  the  nitrate- 


522    INJURIES  AND  SURGICAL   DISEASES  OP  THE  SOFT   PARTS. 

of-silver  stick.  Pressure  also  does  good  service.  When  necessary,  the  granu- 
lations may  be  removed  by  a  sharp  spoon,  the  thermo-cautery,  or  simply  by 
the  knife  or  scissors,  and  the  wound  surface  covered  with  very  small  pieces 
of  skin  by  Thiersch's  method  (§  42). 

Irritable  Ulcer. — By  irritable  ulcer  very  painful  granulations  are  meant, 
which  bleed  easily.  It  is  not  known  upon  what  the  painfulness  of  these 
granulations  really  depends,  and  it  is  the  more  remarkable  from  the  fact 
that  granulation  tissue  usually  possesses  no  nerves.  The  affection  is  observed 
most  commonly  in  ansemic  or  hysterical  individuals.  The  best  treatment 
consists  in  the  application  of  desiccating  powder  dressings  (iodoform,  bis- 
muth, dermatol),  or  in  the  removal  of  the  painful  granulations  by  caustics, 
or,  better,  with  scissors  or  the  sharp  spoon,  followed  by  transplantation  of 
skin,  etc. 


7.  Elephantiasis. — By  elephantiasis  (elephantiasis  Arabiim  or  pachy- 
dermia acquis! ta)  is  understood  an  extensive  hyperplastic  thickening  of 
the  skin  and  subcutaneous  cellular  tissue  over  large  portions  of  the 

body,  most  frequently  observed  up- 
on the  lower  extremities  and  geni- 
tals (Fig.  317).  The  hyperplasia 
of  the  tissues  may  develop  in  eon- 
junction  M'ith  various  chronic  and 
frequently  recurring  inflamma- 
tions, such  as  chronic  eczemas,  ul- 
cerations, chronic  periostites  and 
osteomyelites,  erysipelatous  and 
lymphangitic  processes,  lymph  sta- 
sis, injuries  to  nerves,  etc.  A  sec- 
ond form  of  elephantiasis  is  the 
result  of  a  chronic  affection,  the 
nature  of  which  is  still  unknown, 
and  occurs  endemically  in  tropical 
and  subtropical  countries  (Central 
America,  Arabia,  India),  while  in 
Europe  only  sporadic  cases  are  ob- 
served. In  its  epidemic  form  the 
process  is  due  in  many  instances  to 
the  presence  of  the  filaria  Bancrof  ti 
(or  medinensis),  which,  with  its  em- 
bryos, inhabits  the  lymphatic  vessels  and  causes  lymph  stases  and  in- 
flammations, particularly  of  the  external  genitals,  the  thigh,  and  peri- 
toneal cavity.  The  invasion  of  the  tilaria  does  not  in  every  case  give 
rise  to  elephantiasis,  and  as  a  matter  of  fact  the  parasites  have  not 
been  found  in  the  majority  of  cases.     The  thread-like  worm  is  8  to 


Pig.  317. — Elephantiasis  of  a  native  of  Samoa; 
removal  of  the  scrotum,  which  \veiL''hed 
seventy-eight  poundis,  followed  l)y  recov- 
ery.    (Koniger.) 


^93.]      TUE   DISEASES  OF  THE  SKIN   AND  CELLULAR  TISSUE.        523 

10  centimetres  lon<j,  and  its  larva^  a])ont  0"35  millimetres.  They  prob- 
ably enter  the  human  organism,  the  lymphatic  vessels,  and  the  blood 
from  the  intestine  (Manson,  Scheube). 

The  portions  of  skin  involved  in  the  elephantiasis  are  sometimes 
dense  and  hard  (ele])liantiasis  dura)  and  sometimes  made  up  of  soft, 
greyish-white  tissue  (elephantiasis  mollis),  and  often  contain  greatly  di- 
lated lymphatic  vessels  (elephantiasis  lymphangiectatica).  Ele})liantiasis 
is  occasionally  congenital,  and  may  be  a  result  of  abnormal  development 
and  new  formation  of  blood  and  lyinphatic  vessels  (elephantiasis  con- 
genita telangiectodes  and  E.  lymphangiectodes).  (See  also  Tumours.) 
In  rare  instances  an  inherited  elephantiasis  is  observed,  which,  accord- 
ing to  Nonne,  is  probably  the  result  of  an  inherited  defect  in  the  de- 
velopment of  the  lymphatic  system. 

Treatment  of  Elephantiasis. — -The  treatment  of  elephantiasis  in  the 
beginning  of  the  disease  is  directed  towards  the  cause,  particularly  the 
inliammatory  changes  in  the  affected  portions  of  the  body.  Enveloping 
the  parts  in  elastic  bandages,  placing  them  in  an  elevated  position,  in- 
jections of  alcohol,  ligation  of  the  main  afferent  artery,  punctate  cau- 
terisation, repeated  spindle-shaped  excisions,  and  total  removal  of  an 
elephantiatic  scrotum  or  of  the  affected  extremities  by  amputation  or 
disarticulation,  have  all  been  employed  (see  Special  Surgery). 

8.  Myxoedema. — Mj'xoedema  is  a  very  rare,  easily  recognised  affection 
of  great  pathological  interest.  The  disease,  which  was  first  described 
by  Gull  in  1873  as  the  "  cretinoid  condition,"  affects  women  more  often 
than  men,  especially  those  of  middle  age.  There  is  always  a  destructive 
change,  such  as  fibroid  degeneration,  interstitial  connective-tissue  de- 
velopment, or  other  disease  of  the  thyroid  gland,  the  latter  being  some- 
times enlarged  and  sometimes  atrophic.  Myxcedema  has  also  been  ob- 
served in  connection  with  syphilitic  disease  of  the  thyroid  gland.  The 
interstitial  connective-tissue  growth  generally  present  in  the  thyroid 
is  mainly  the  result  of  an  inflanmiatory  process,  and  is  also  very  fre- 
quently found  in  the  skin  and  in  the  internal  organs.  A  pronounced 
excess  of  mucin  is  found  in  the  skin  and  blood  ;  the  amount  of  haemo- 
globin in  the  blood  is  diminished,  while  the  amount  of  red  corpuscles 
and  fibrin  varies,  being  sometimes  diminished  and  sometimes  increased. 
The  power  of  the  red  blood-corpuscles  to  take  up  oxygen  may  be 
greatly  diminished.  The  skin,  particularly  of  the  face  and  extremities, 
is  characteristically  swollen.  There  are  also  disturbances  of  speech,  of 
motion,  and  of  intellect,  and,  in  brief,  a  remarkable  decline  of  the  bod- 
ily and  mental  functions.  In  youthful  individuals  the  normal  develop- 
ment does  not  take  place  (dwarfs,  etc).  Myxcedema  is  extremely  rare 
in  childhood. 


52-i  INJURIES  AXD   SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 

By  experimental  extirpation  of  the  tliyroid  gland  in  animals,  and  by 
its  total  extirpation  in  man,  there  is  produced  a  form  of  disease,  the 
so-called  cachexia  strumipriva  or  thyreopriva,  which  corresponds  in 
all  respects  to  myxcedema,  and  hence  only  a  j^ar^mZ  removal  of  the 
tliyroid  gland  is  allowable  in  man.  Myxoedema  has  also  been  observed 
after  partial  extirpation  of  the  degenerated  gland  when  the  retained 
portion  atrophied  with  remarkable  rapidity  (Kohler).  Schiff  and 
Eiselsberg  demonstrated  that  animals  withstand  total  extirpation  of  the 
thyroid  gland  if  their  own  thyroid  gland,  or  one  taken  from  another 
animal  of  the  same  species,  is  successfully  implanted  in  the  peritoneal 
cavity  and  resumes  its  normal  function  there.  The  function  of  the 
thyroid  gland,  which  is  to  prevent  the  accumulation  in  the  body  of 
mucin,  is  disturbed  in  myxoedema.  Therefore  myxoedema  may  origi- 
nate from  operative  removal  as  well  as  from  degeneration  of  the  thy- 
roid gland,  and  is  probably  identical  with  the  so-called  sporadic  cretin- 
ism which  occurs  in  children,  and  is  closely  related  to  endemic  cretinism. 
The  ultimate  causes  of  degeneration  of  the  thyroid  gland  are  unknown. 
Myxoedema  usually  terminates  fatally  in  a  few  years.  According  to 
Bircher  and  others,  myxoedema  and  cretinism  are,  in  respect  to  their 
etiology,  pathogenesis,  and  course,  totally  different  processes.  As  re- 
gards treatment,  Horsley  recommends  the  implantation  of  the  thyroid 
gland  after  total  extirpation  of  the  gland,  and  for  myxcedema.  In  one 
case  of  myxo?dema,  which  had  existed  for  four  to  five  years.  Murrey 
obtained  remarkable  improvement  by  ten  injections  of  the  extract 
from  two  and  a  half  thyroid  glands  taken  from  sheep. 

Scleroderma. — By  scleroderma  is  understood  a  circumscribed,  or  more  dif- 
fuse hardening  of  the  skin,  occurring  rather  suddenly  in  adults,  without  ex- 
ternal causes,  and  either  remaining  stationary  or  gradually  extending,  and 
finally  terminating  in  atrophy.  In  scleroderma  the  skin  is  as  hard  as  wood, 
and  the  disease  occurs  on  the  trunk,  the  face,  and  the  extremities.  Its  nature 
is  unknown.  Anatomically,  Chiari  found  a  thickening  of  the  fibrous  stroma 
of  the  skin  combined  in  places  with  an  infiltration  with  leucocytes.  In  one 
case  Heller  found  obliteration  of  the  thoracic  duct. 

Scleroderma  neonatorum,  according  to  Langer.  is  caused  by  a  stiffening 
and  hardening  of  the  subcutaneous  cellular  tissue  in  conditions  of  collapse 
and  lowered  body  temperature. 

Idiopathic  Atrophy  of  the  Skin.— Idiopathic  atrophy  of  the  skin  is  an  ex- 
ceedingly rare  disease,  and  the  etiology  is  obscure.  Sometimes  excessive 
cold  or  heat,  nervous  influences,  etc.,  appear  to  be  the  cause.  The  atrophic 
areas  of  skin  slowly  increase  in  circumference,  and  eventually  lead  to  cor- 
responding disflgiu-ements.  As  yet  it  has  been  impossible  to  find  a  success- 
ful treatment. 

Dermatolysis.— In  the  so-called  dermatolysis  (Tilbury,  Fox),  the  skin, 
without  apparent  change  in  structure,  becomes  too  abundant  and  loose,  giv- 


§'J4.]  DISEASES  OF   THE   MUCOUS   MEMBRANES.  525 

in^  rise  to  folds.  The  faces  of  youthful  individuals  may  thus  assume  an 
aged  expression. 

For  tumours  of  the  skin,  see  Tumours,  §§  125-130. 

§  94.  Inflammations  and  Surgical  Diseases  of  the  Mucous  Membranes. 

— Diseases  of  Mucous  Jleiubrancs  of  /Surgical  Jinjjortancc. — iJriet 
mention  will  be  made  here  only  of  those  diseases  and  inflammations  of 
mucous  membranes  which  are  the  object  of  surgical  treatment.  "\Ve 
shall  discuss  injuries  in  the  Special  Surgery.  As  a  general  rule, 
wounds  of  mucous  membrane,  if  strict  asepsis  is  observed,  heal  readily, 
particularly  under  the  use  of  iodoform. 

Acute  Inflammation. — Acute  inflammation  of  the  mucous  mem- 
branes occurs  as  an  acute  catarrh  or  acute  catarrhal  inflammation 
which  is  characterised  by  hypersemia,  oedematous  swelling,  and  the 
formation  of  a  discharge  at  flrst  poor  in  cells  and  then  containing 
large  quantities  of  them.  Some  of  the  cells  are  extravasated  colour- 
less blood-corpuscles,  and  others  desquamated  epithelium.  Not  infre- 
quently in  catarrh  tliere  is  a  development  of  vesicles  and  superficial 
losses  of  substances — catarrhal  ulcers.  The  causes  of  catarrhs  may  be 
mechanical  or  chemical  in  nature,  or,  what  is  most  common,  they  may 
be  due,  in  the  main,  to  micro-organisms,  as  is,  for  instance,  the  acute 
catarrh  of  the  mucous  membrane  of  the  genitals — gonorrhoea  (see  page 
433).  Catarrhs  which  occur  as  a  result  of  chemical  irritations  are  pro- 
duced, for  example,  by  the  action  of  mercury  or  iodine ;  many  individ- 
uals are  very  susceptible  to  these  two  substances.  The  acute  inflam- 
mations which  follow  the  use  of  mercury  and  attack  the  cavity  of  the 
mouth,  for  example  (stomatitis  mercurialis),  are  occasionally  observed 
during  the  treatment  of  a  wound  with  bichloride,  or  dunng  the  in- 
unction treatment  of  syphilis,  etc.  (see  page  434).  Mercurial  stomatitis 
is  characterised  by  a  swelling  of  the  gums,  salivation,  swelling  of  the 
mucous  membrane  of  the  mouth  at  various  points,  and  the  formation 
of  ulcers.  Mercurial  stomatitis,  as  we  shall  see,  is  best  prevented  by 
cautious  use  of  bichloride  in  the  treatment  of  wounds,  by  paying  care- 
ful attention  to  the  cleanliness  of  the  mouth,  by  stopping  smoking  dur- 
ino'  the  inunction  treatment,  etc.  The  treatment  of  the  mercurial  sto- 
matitis  itself  consists  in  gargling  the  throat  with  chlorate  of  potash  or 
boric  acid.  This  complication  can  usually  be  speedily  cured  by  super- 
ficial cauterisation  of  the  ulcers  with  silver  nitrate  or  copper  sulphate  in 
substance,  and  also  by  stopping  the  bichloride  dressings  or  the  inunctions. 

Cancrum  oris  or  noma  is  a  severe  ulcerative  stomatitis,  which  will 
be  discussed  in  the  Special  Surgery,  with  the  other  diseases  of  mucous 
membranes  in  the  facial  cavities,  the  digestive  tract,  genito-urinary 
apparatus,  etc. 


526    INJURIES  AND  SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 


YB 


o 


Sch 


3. — Croupous    membrane   (B)  upon  a 
;ous  membrane  (/St7<),  consisting  of  a 


Fig.   318. 
mucous 

network  of  tibrin  which  is  tilled  with  leu- 
cocytes.    X  150. 


M 


Si 


Croupous  and  Diphtheritic  Inflammation. — Bj  croup  and  diphtheria 
inflammatory  processes  are  understood  which   are  for  the  most  part 

identical  pathologically  and  clin- 
^  ically,  and  only  differ  in  degree. 
Both  inflammations  are  charac- 
terised by  the  formation  of  an 
inflammatory  product  consisting 
of  fibrin  and  cells,  which  is 
slightly  adherent  to  the  surface 
of  the  mucous  membrane.  In 
croup  (Fig.  318)  the  membrane 
lies  upon  the  mucous  mem- 
brane, while  in  diphtheria  the 
exudate  is  also  found  in  the 
mucous  membrane,  and  the  latter  becomes  more  or  less  necrotic  (Fig. 
319).  In  the  formation  of  this  pseudo-membrane,  according  to  Baum- 
garten,  the  "fibrinous"  degeneration  of  the  epithelium  plays  an  iin- 

portant  part  as  well  as  the 
fibrinous  exudate.  In  croup 
there  is  a  fil)rinoid  degenera- 
tion of  the  epithelium  only,  but 
in  dijjhtheria  this  process  also 
involves  the  connective  tissue. 
The  local  death  of  tissue  pro- 
duced by  the  diphtheritic  in- 
flammation is,  according  to 
Cohnheim  and  AVeigert,  a  coag- 
ulation necrosis — i.  e.,  a  death 
of  the  tissues  and  cells  due  to 
the  coagulation  of  lymph  which 
permeates  the  affected  tissues 
and  penetrates  into  the  cells. 
The  croupous  and  diphtheritic 
membranes  come  away  after  a 
certain  length  of  time,  being 
cast  off  by  the  new  epithelium 
which  is  produced  underneath  and  pushes  the  remains  of  the  mem- 
brane before  it ;  in  severe  cases  the  membrane  comes  away  in  toto 
(Heubner).  Croup  can  be  excited  experimentally  by  the  injection  of 
liq.  ammonii  caustici  into  the  trachea  of  a  rabbit,  the  animals  usually 
dying  in  two  to  three  to  four  days  with  symptoms  of  asphyxia.  Thei-e 
is  no  anatomical  distinction   between   this   experimental   croup   and 


It/*'-:- 


B 


Fig.  310. — Section  through  the  uvula  in  diphtheri- 
tis  faueium  at  the  border  of  the  healthy  tissue  : 
A,  normal  epithelium  and  submucous  tissue  ; 
7>,  the  connective  tissue  underneath  the  epithe- 
lium and  mucous  membrane  infiltrated  with 
librin.  leucocytes  and  red  blood-corpuscles;  J/, 
masses  of  micrococci,      x  120. 


g94.]  DISEASES  OF   THE   MUCOUS   MKMmiANPX  527 

epidemic  dij)litlicria  (Ariddeldorpf,  Goldnianii).  The  pliarynx  and 
trachea  are  must  frecpiently  alt'ected  by  tlie  croupous  and  diphther- 
itic inflammation  ;  less  often  the  mucous  membrane  of  the  bladder 
and  intestine.  Diphtheria  occasionally  occurs  in  the  skin,  starting, 
for  example,  from  infection  through  a  cutaneous  abrasion  or  wound, 
especially  in  the  neighbourhood  of  mucous  membranes  such  as  that 
of  the  female  genital  tract,  the  rectum,  etc.  True  diphtheria  is  an 
infectious  disease  which  is  produced  by  a  specific  bacillus  discovered 
])y  Loffler,  and  is  to  be  carefully  distinguished  from  all  other  patho- 
logical processes  which  are  likewise  accompanied  by  the  formation 
of  croupous  or  diphtheritic  changes  in  the  mucous  membranes  and 
do  not  differ  anatomically  from  true  diphtheria  (so-called  pseudo- 
diphtheria).  By  temporarily  interrupting  the  circulation  of  blood 
in  the  urinary  bladder  Heubner  excited  artificially  a  local  pseudo- 
diphtheria  of  this  description  which  was  not  transmissible  to  animals 
by  inoculation  like  true  diphtheria.  In  true  diphtheria  there  develops, 
as  a  result  of  the  absorption  of  the  poisonous  products  of  the  bacterial 
metabolism,  a  febrile  systemic  intoxication  the  severity  of  which  varies 
greatly,  though  it  very  often  speedily  terminates  in  death,  particularly 
when  a  degeneration  of  the  muscles  of  the  heart  takes  place.  Amongst 
other  sequelae  of  diphtheria,  nephritis  (albuminuria)  and  paralyses  are 
especially  prominent.  In  the  latter  there  occur  histologically  pro- 
nounced inflammatory  changes  in  the  muscles  and  nerves  (Hochhaus). 
The  symptomatology  of  diphtheria  is  discussed  in  the  Special  Surgerv. 
See  also  AVound  Di])htlieria,  §  72. 

The  Etiology  of  Diphtheria— Lbffler's  Diphtheria  Bacillus.— Loffler  was 
the  fii*st  to  prove  the  constant  presence  of  a  species  of  bacteria  in  human 
diphtheria  ;  he  cultivated  it  artificially  and  inoculated  animals  with  it.  It 
was  impossible  to  excite  genuine  diphtheria  in  animals,  but  Loffler  was  able 
to  prove  that  the  bacteria  in  question  had  pronounced  poisonous  properties. 
Fraukel  and  others  have  confirmed  Loffler  s  statemeuts,  and  Roux  and  others 
successfully  inoculated  animals  with  Loffler's  bacillus  and  observed  the 
symptoms  which  are  peculiar  to  human  diphtheria,  particularly  the  forma- 
tion of  local  diphtheritic  processes  and  the  paralyses  which  follow  the  general 
intoxication.  Upon  the  basis  of  these  facts,  we  are  justified  in  the  belief  that 
Loffler's  bacillus  is  the  actual  excitant  of  diphtheria. 

The  diphtheria  bacilli  are  small  rods  about  as  long  as  tubercle  bacilli, 
though  almost  twice  as  thick,  of  a  plump  appearance,  and  generally  with 
rounded  ends  (Fig.  B20).  They  vary,  however,  greatly  in  their  form,  the 
rods  having  frequently  a  club-shaped  thickening  at  the  end,  while  others  are 
in  process  of  division  into  several  pieces  by  transverse  segmentation  (mani- 
festations of  involution).  The  bacilli  are  found  in  the  diphtheritic  pseudo- 
membrane,  and  nowhere  else  in  the  body  ;  consequently  the  severe  constitu- 
tional symptoms  of  diphtheria  are  caused  by  the  exceedingly  poisonous  prod- 


528    INJURIES  AND  SURGICAL   DISEASES  OP  THE  SOFT  PARTS. 

ucts  of   their   metabolism.      Opinions  vary  as  regards   the   nature  of  the 

toxines  of  the  diphtheria  bacilli,  though  they  are  generally  considered  to  be 

albuminoid  bodies  belonging,  according  to  Brieger  and  Frankel,  to  the  toxal- 

bumens,  according  to  Roux  and  Yerein  to  the  diastases,  and  according  to  Ga- 

maleia  to  the  nuclein  compounds.     They  are  formed  eitlier 

*^    -^^  by  the  decomposition  of  the  albuminous  bodies  contained  in 

Q    \f  q    ^    the  nutritive  substances,  or  the  microbes  develop  them  with- 

o  |>  y  V       ^        in  themselves  by  synthesis  of  simpler  bodies  (Guinochet, 

"  \  •'''"^     Strauss).     The  toxic  substances  of  the  diphtheria  bacilli  are 

„  J,,  •,!•     marked  by  a  certain  instability  being  destroyed  by  heat  and 

of      diphtlieria,     ferments  (pepsin,  pancreatiu),  and  passing  through  the  di- 

X  1200:  a,  young     nrestive  tract  without  causing  any  disturbance  (Gamaleia). 

bacilli     from     a      X,,       ,.    ,    i       .  •  •  •      i      •  i     ii  i  t  i 

fresh  culture;  b,     The  diphtheritic  poison  is  decidedly  weakened  by  antipyrm 

involution  forms     (Vianna).      Mixed  (septic)   infections  originate   from   the 
(Loffler).  ^  •'  .„  ,  .,  ,, 

presence  at  the  same  time  of  streptococci  and  staphylococci. 

The  bacilli  are  facultative  anaerobic,  and  incapable  of  movement  ;  they 
grow  at  temperatures  ranging  between  68°  and  104°  F.  upon  gelatine  or  other 
nutritive  medium,  which  must  always  be  made  slightly  alkaline,  and  espe- 
cially well  upon  Loffler's  blood  serum  (three  parts  blood  serum  from  cattle 
or  sheep,  one  part  beef  bouillon,  one  per  cent,  peptone,  one  half  per  cent, 
common  salt,  one  per  cent,  grape  sugar)  and  upon  glycerine-agar.  On  Loffler's 
blood  serum  a  thick,  glistening,  whitish  scum  forms  in  the  incubator  at  a 
temperature  of  98-4°  F.  in  about  two  days.  On  glycerine-agar  at  the  incubator 
temperature,  flat,  greyish-white,  glistening  colonies, 
with  smooth  edges,  the  size  of  a  millet  seed,  develop 
within  twenty-four  to  forty-eight  hours  (Fig.  321). 
On  agar  the  cultures  at  first  grow  slowly,  but  the 
second  generation  more  luxuriantly,  as  the  bacilli 
have  then  become  accustomed  to  the  nutritive  medi- 
^"^^^^^^n'  um,  w^hich  was  not  at  first  suited  to  them.     But  at 

the  same  time  they  suffer  a  loss  in  virulence.  When 
stab  cultures  are  made  in  gelatine,  small  white  glob- 
ular colonies  develop  along  the  inoculated  line  of 
puncture.  On  gelatine  plates,  at  a  temperature  of 
22°  to  24°  C.  (71°  to  75°  F.),  the  colonies  remain  small 
and  the  gelatine  is  not  liquefied.  The  bacillus  grows 
upon  potatoes  provided  the  surface  is  made  alkaline ; 
milk  is  also  an  excellent  nutritive  medium.      At 

Fig.  S21.  -  Dmhtheria  ba-     temperatures  ranging  from  45°  to  50°  C.  (113°  to  122° 
cillus.        Colony    upon  \  .  ,         o  r  i-        -u  ^i 

agar,  twenty-four  liours     F. )  the  baciUi  perish.     Spore  formation  has  ^lot  been 

ofd,      unstainea,  X  100     oi^geryed.      The  bacilli  are  also  possessed  of  great 

(trankel  and  rteitier).  .  .       .  i   ■    ^ 

powers  of  resistance ;  they  will  remain  in  a  dried 

pseudo-membrane  and  be  capable  of  development  after  the  lapse  of  three  to 

four  months.     Roux  and  Yersin  demonstrated  that  serum  cultures,  under 

ordinary  conditions,  retain  their  vitality  and  virulence  for  five  mouths;  and, 

furthermore,  that  the  cultures  kept  entirely  shut  off  from  the  action  of  air 

and  light  still  possess  their  full  virulence  after  the  lapse  of  thirteen  months. 

The  diphtheria  bacilli  can  be  best  stained  with  Loffler's  alkaline  methyl 

blue  solution;  they  do  not  stain  by  Gram's  method.     But,  according  to  the 


§94.]  DISEASES  OF  THE   MUCOUS  MEMBRANES.  520 

recent  investifjations  of  Roux  and  Yersin,  the  latter  method  can  also  be 
easily  used.  The  virulent  diphtheria  bacilli  are  almost  never  found  in  the 
mucus  of  the  mouth  of  a  man  who  is  healthy  or  who  has  some  other  disease, 
but  Lotller  and  Hofmann  state  that  pseudo-diphtheria  bacilli  are  often  found 
which  are  very  similar  but  have  no  ])athog'enic  action,  and  are  to  be  regai-ded 
as  possibly  weakened  forms  of  the  diphtheria  bacilli. 

Transmission  of  Diphtheria  to  Animals. — Inoculations  in  animals  are 
often  unsviccessful  ;  j^uinea-pigs,  rabbits,  doves  and  chickens  are  particularly 
susceptible,  while  mice  and  rats  are  not  very  much  so.  In  guinea-pigs,  doves, 
etc.,  the  cultures  excite  pseudo-membranes  in  the  trachea,  and  sometimes 
.severe  constitutional  symptoms,  paralyses,  etc.  Guinea-pigs  are  the  most 
susceptible  ;  within  a  few  days  after  subcutaneous  inoculation  they  die  with 
cedema,  pleuritic  effusions,  etc.,  but  the  bacilli  are  not  found  in  the  internal 
organs.  Filtered  cultures,  or  the  poisonous  albuminous  bodies  (toxalbumens) 
isolated  from  the  cultures  excite  severe  symptoms  of  intoxication,  which, 
however,  take  a  long  time  to  cause  death. 

Artiiicially  Acquired  Immunity  from  Infection  by  Diphtheria. — Behring 
and  Kitasato  have  made  animals  artificially  immune  from  diphtheria  (1)  by 
the  use  of  cultures  sterilised  by  Frankel's  method  ;  (2)  by  the  addition  of 
iodoform  to  the  cultures  ;  (:?)  by  subcutaneous  and  intra-abdominal  injection 
of  the  pleuritic  exudate  which  frequently  forms  in  diphtheritic  animals  ;  (4) 
by  subcutaneous  injection  of  iodoform  very  soon  or  a  few  hours  after  the 
infection  with  diphtheria.  It  is  also  possible  to  give  animals  an  increased 
power  of  resistance  against  diphtheritic  infection  by  the  administraion  of  per- 
oxide of  hydrogen  for  a  few  days  before  the  infection.  By  inoculating  guinea- 
pigs  with  sterilised  culture  flviids  heated  for  a  few  hours  to  between  60°  and 
70°  C.  (140°  and  168°  F.),  C.  Frankel  obtained  immunity  after  the  lapse  of 
fourteen  days.  Two  kinds  of  substances  are  found  in  the  culture  fluids  of 
diphtheria  bacilli — viz.,  a  toxic  substance  which  is  destroyed  when  heated  to 
55°  to  60°  C.  (131°  to  140°  F.),  and  an  immunising  substance.  According  to 
Behring  and  Kitasato,  the  r.nimals  which  have  been  rendered  immune  are 
not  only  protected  from  infection  with  living  diphtheria  bacilli,  but  also  from 
the  injurious  effects  of  the  poisonous  products  of  their  metabolism.  Never- 
theless, the  immunity  may  be  again  lost  by  repeated  injections  of  consider- 
able amounts  of  poison,  especially  if  the  immunity  has  not  been  sufHciently 
firmly  established.  The  artificially  acquired  insusceptibility  to  diphtheria 
depends  upon  changes  in  the  serum  of  the  blood  of  the  animals  in  question. 
Behring  has  consequently  recommended  the  subcutaneous  injection  of  this 
immunising  serum  as  a  therapeutic  measure  for  diphtheria  in  man.  No  defi- 
nite judgment  can  be  pronounced  as  yet  upon  the  success  of  this  method  of 
treatment. 

Spread  of  Diphtheria.— The  bacillus  of  diphtheria  varies  in  the  degree  of 
its  virulency  at  different  times.  This  explains  why  the  course  of  diphtheria 
in  different  cases  and  in  different  epidemics  is  so  dissimilar.  Diphtheria 
spreads  by  contagion  ;  the  membranes  which  are  coughed  up,  the  sputa  and 
the  saliva  are  the  most  common  sources  of  infection.  During  convalescence 
the  bacilli  remain  alive  in  the  mouth  for  about  three  weeks  ;  in  a  dried  con- 
dition they  may  persist  in  thick  layers  for  three  to  four  months,  and  in  a 
half-dried  condition  for  seven  months.  Toys,  eating  and  drinking  utensils, 
34 


530    INJURIES   AND   SURGICAL   DISEASES  OF  THE  SOFT   PARTS. 

kissing,  etc.,  sometimes  cause  tlae  spread  of  the  disease.  An  ectogenous  de- 
velopment of  diphtheria  bacilli  sometimes  takes  place  in  articles  of  food, 
such  as  milk.  The  individual  predisposition  to  diphtheria  decreases  very 
much  after  the  thirteenth  year.  A  pharyngeal  mucous  membrane  affected 
with  or  having  a  tendency  to  catarrh  is^  favourable  soil  for  the  lodgement 
of  the  diphtheria  bacillus.  To  prevent  the  starting  and  spread  of  diphtheria, 
the  patients  should  first  of  all  be  strictly  isolated  in  every  respect,  and  objects 
coming  in  contact  with  them  should  be  properly  disinfected. 

Other  Bacteria  Streptococci  and  Staphylococci  present  in  Diphtheria.— 
In  addition  to  the  diphtlieria  bacilli  there  are  very  frequently — iu  fact  almost 
always — found  streptococci.  These  appear  to  have  no  bearing  upon  the 
diphtheria  as  such,  but  may  give  rise  to  general  septic  infection — mixed  in- 
fection (Beck.  Barbier.  etc.).  But,  according  to  Baginsky,  there  is  a  form  of 
diphtheria  which  clinically  is  like  true  diphtheria,  but  is  not  dangerous,  and 
terminates  in  recovery  ;  in  this  Loffler's  bacillus  is  not  present,  and  Baginsky 
only  found  streptococci  and  staphylococci. 

The  Pseudo-Diphtheria  Bacillus. —In  addition  to  the  diphtheria  bacillus, 
which  is  the  excitant  of  true  diphtheria.  Loffler  and  others  have  described  a 
pseudo -diphtheria  bacillus  which  is  morphologically  and  biologically  slight- 
ly different  from  the  true  diplitheria  bacillus.  It  is  somewhat  shorter  and 
thicker,  grows  luxuriantly  at  a  temperature  of  20°  to  22°  C.  (C8°  to  72°  F.) 
in  bouillon,  and  changes  the  reaction  of  bouillon  more  rapidly,  forms  upon 
serum  a  more  yellow  scum,  audioes  not  thrive  as  well  in  the  absence  of  air 
as  the  true  diphtheria  bacillus.  When  inoculated  in  animals,  local  manifes- 
tations are  sometimes  observed,  but  death  never  occurs  (Roux,  Yersin).  The 
pseudo-diphtheria  bacillus  is  fovmd  in  the  mouths  of  healthy  individuals,  and 
in  simple  sore  throats.  According  to  Roux  and  Yersin,  a  certain  relation- 
ship exists  between  the  two  kinds  of  bacilli.  They  succeeded  in  permanently 
changing  very  virulent  true  diphtheria  bacilli,  by  the  action  for  several  days 
of  a  steady  stream  of  air,  to  such  an  extent  that  they  behaved  like  pseudo- 
diphtheria  bacilli;  and  on  the  other  hand,  by  simultaneous  inoculations  with 
erysipelas  cocci,  they  were  able  to  restore  to  the  weakened  diphtheria  bacilli 
their  full  virulence,  but  not  to  the  pseudo  diphtheria  bacilli. 

"^  §  95.  Inflammations  and  Diseases  of  Blood-vessels. — The  acute  inflam- 
mations of  the  arteries  and  veins — arteritis  and  phlebitis — have  been 
described  in  §  69  and  §  To  (pyaemia) ;  and  the  various  changes  wliich 
thrombi  undergo,  including  the  cicatricial  closure  of  a  vessel,  the  so- 
called  organization  of  a  thrombus,  were  discussed  in  §  61.  There  re- 
mains for  us  to  tate  up  chronic  inflammations  of  the  walls  of  the  ves- 
sels, as  well  as  aneurysms  and  varices. 

Chronic  Inflammations  of  the  Walls  of  the  Vessels. — The  fatty,  amy- 
loid, and  hyaline  degenerative  changes  occurring  in  vessels  belong 
more  to  the  domain  of  pathological  anatomy,  but  hypertrophic  con- 
ditions in  the  arteries  have  also  a  surgical  importance.  The  develop- 
ment of  the  collateral  circulation  after  occlusion  of  a  vessel  or  the  for- 
mation of  an  aneurysma  racerao:iim  (see  Aneurysms)  depends  upon  a 


^i)ry.]       LNFLAMMATIONS   AND   DISEASES  OF   BLOOD-VESSELS.         531 

hyperplasia  of  all  the  arterial  coats.  (Jhrouic  oiularteritis  is  particu- 
larly iiri])ortant ;  it  consists  in  a  liypertroj)liy  of  the  intima  from  a 
circumscribed  or  more  diffuse  growth  of  connective  tissue.  In  this 
class  belongs  the  endarteritis  obliterans  of  syphilis,  for  example,  and 
endarteritis  deformans  (arterio-sclerosis  or  atheroma).  Nodular  or 
more  diffuse  thickenings  of  the  arteries  develop  from  inflammations 
in  the  parts  surrounding  the  arteries — in  other  words,  from  periarteritis. 
Phlebitis  hyperplastica  and  periphlebitis  chronica  are  much  rarer  than 
chronic  arteritis,  and  the  pathological  changes  are  not  by  any  means  so 
pronounced. 

Endarteritis  Obliterans. — The  endarteritis  of  syphilis  was  first  accu- 
rately described  by  lleubner ;  it  occurs  either  independently  and  by 
itself,  or  within  a  focus  of  syphilitic  inflammation.  The  process  be- 
gins with  a  cellular  infiltration  of  the  intima,  which  subsequently 
changes  into  connective  tissue;  the  media  remains  more  or  less  intact, 
or  likewise  changes  into  fibrous  tissue.  The  thickening  of  the  walls 
of  the  vessels  in  syphilis  is  not  infrequently  very  considerable,  and  the 
lumen  of  the  arteries  may  not  only  be  narrowed,  but  even  completely 
closed.  The  syphilitic  inflammation  also  occurs  in  the  intima  of  the 
veins.  As  Friedlander  in  particular  has  pointed  out,  there  occurs  not 
only  in  syphilis,  but  also  in  various  other  chronic  inflammatory  condi- 
tions, an  obliterating  endarteritis  from  proliferation  of  the  endothelium 
of  the  larger  arteries  as  well,  which,  when  it  affects  an  extremity,  may 
threaten  the  integrity  of  the  whole  limb.  Riedel  observed  gangrene 
of  the  leg  following  a  circumscribed  obliterating  endarteritis  of  the 
femoral  artery  in  a  woman  thirty-six  years  of  age.  Circumscribed  or 
more  diffuse  infiltrations  of  the  walls  of  the  vessels  are  also  produced 
by  tubercular  inflammation  of  these  walls. 

Congenital  stenosis  of  the  aorta  (Morgani,  Virchow,  Friintzel,  etc.) 
is  a  matter  of  more  consequence  to  the  physician. 

Sclerosis  or  Atheroma  of  the  Vessels. — Atheroma  of  the  arteries  (arte- 
rio  sclerosis)  is  mainly  a  disease  of  old  age,  and  is  particularly  apt  to 
follow  the  habitual  use  of  alcohol.  It  consists  of  thickenings  of  the 
intima,  which  occur  in  patches."  The  thickened  parts,  especially  at  the 
outset,  are  soft  and  jelly-like,  or  dense  and  fibrous,  or  more  cartilagi- 
nous in  character.  The  atheromatous  patches  often  become  calcified, 
or  the  tissue  may  break  down  and  give  rise  to  losses  of  substance  (athe- 
romatous ulceration).  Atheroma  may  occur  in  all  parts  of  the  arterial 
system,  from  the  valves  of  the  aorta  to  the  smallest  arteries,  and  is 
sometimes  developed  to  an  extreme  degree.  Atheroma  of  the  veins  is 
more  rare,  and  never  of  as  high  a  grade.  It  is  essentially  an  endar- 
teritis which   begins  with   inflammatory  infiltration,  and   leads   to   a 


532    INJURIES  AND  SURGICAL  DISEASES  OF   THE  SOFT   PARTS. 


Fig.  322. — Various  forms   of  aneurysms:   a,  cylindrical 
aneurysm  ;  b,  spindle-shaped  ;  c.  sacculated  aneurysm. 


new  formation  of  connective  tissue.  This  is  followed  by  retrogressive 
changes  (fatty  degeneration,  necrosis,  calcification).  As  a  result  of 
arterio-sclerosis  there  occur  a  thickening,  narrowing,  or  occlusion  of 
the  vessels,  with  secondary  disturbances,  and  finally  necrosis  of  the 

parts  supplied  by  the  af- 
fected vessel,  as  in  senile 
gangrene  (see  Special  Sur- 
gery). On  the  other  hand, 
dilatation  and  rupture  of 
the  walls  of  the  artery  oc- 
cur if  the  media  also  de- 
generates and  loses  its 
powei*  of  resistance. 

Aneurysms. — By  aneu- 
rysm is  understood  a  dila- 
tation of  an  artery  filled 
with  flowing  blood.  The 
dilatation  is  'either  limited 
to  a  certain  portion  of  the 
artery  (Fig.  322),  or  there  is  an  expansion  of  a  whole  group  of  arterial 
branches  and  of  capillaries  with  a  simultaneous  hypertrophy  of  their 
walls  (Fig.  327).  The  latter  form  of  aneurysm  is  called  aneurysma 
racemosum  or  anastomoticum. 

Aneurysms  originate  either  from  injuries  or  from  gradual  dilatation 
of  the  vessel  as  a  result  of  disease  of  its  wall,  especially  chronic  endar- 
teritis (atheromatous,  syphilitic  endarteritis),  and  periarteritis  with  sec- 
ondary atrophy  of  the  wall,  particularly  the  media.    Kohler  saw  a  large 

axillarj'  aneurysm 

which  was  caused 

by   an    echinococ- 

' ""  ens  in  the   sheath 

of  the  artery.    All 

^^   primary   and   sec- 

.^'       '         ondary  diseases  of 

^  the   walls   of    the 

TT     ooo     ,  /  ,^    *  »v,    K    J    ^ ».       vessels    by    which 

Fig.  Z2S. — Aneurysma   ..,v^:.     ..;.  .-..;ii  (A)  at  the  bend  of  the  -^ 

elbow,  resulting  from  a  venesection  (Bell;.     The  aneurjsmal      the      Strength     and 
sack  ^4  is  cut  open  (Froriep).  .    ,  p      .^ 

elasticity  oi  tlie 
walls  are  diminished  may  give  rise  to  the  formation  of  an  aneurysm. 
According  to  the  views  of  Koster  and  Krafft,  true  aneurysms  originate 
mainly  from  inflammatory  processes  in  the  media  ;  but  Recklinghausen, 
Manchot  and  others  insist  chiefly  upon  the  presence  of  primary  ruptures 


^95.J        INFLAMMATIONS  AND   DISEASES  OP   BLOOD-VESSELS. 


i33 


Fig.  3'24. — Aneurysiiia  ititcno-vfiioMini :  a,  hra- 
•    chial  iirter>  ;'i,  venaiiicdiana.     The  sack  ot 
the  aneurvMii  which  coiimiunicates  with  the 
artery  and  vein  is  cut  open  (Dorsey). 


of  the  media  due  to  some  traumatism,  and  a  marked  elevation  of  the 
hlood  pressure  followinor,  for  example,  some  violent  exertion  ;  by  these 
injurious  influences  the  powers  of  resistance  i)osseHsed  by  the  arterial 
walls  are  lessened.     An  embolus  lodgiui^  in  a  branch  of  an  artery  may 
also  cause  an  aneurysm — for  ex- 
ample, calcilied  endocarditic  vege- 
tations  may  bore  their  way  into 
the  wall  of  an  artery,  possibly  in 
the  brain,  and  erode  it,  causing  it 
to  give  way  and  dilate — embolic 
aneurysms  (Ponfick).     Moreover, 
aneurysms  may  occasionally  result 
from  emboli  of  a  suppurative  or 
septic   character   with    secondary 
necrosis  of  the  wall  of  the  vessel 
following   endarteritis   or  periar- 
teritis (Biiday,  etc.).     All  aneurysms  developing  from  a  gradual  dilata- 
tion of  all  the  coats  of  the  vessel  used  to  be  called  true  aneurysms 
(aneurysma    vera),    in   contradistinction  to  the   traumatic  aneurysms, 
which  were  designated  Si&  false  (aneurysma  spuria),  from  the  fact  that 
their  walls  do  not  consist  of  all  three  arterial  coats.     This  distinction, 
as    Cohnheim    has    correctly    re- 
marked, is   an  artificial   one  and 
incorrect.     Traumatic  aneurysms 
from  a  punctured  injury,  for  ex- 
ample,   are    brought   about   by  a 
gradual  yielding  of  the  thrombus 
in  the  wall  of  the  vessel  and  of 
the  surrounding  cellular  connect- 
ive tissue,  as  a  result  of    the  in- 
tra-arterial  pressure.     A  sack  thus 
finally  develops,  the  walls  of  which 
are  made  up  of  the  outermost  lay- 
ers of  the  thrombus,  the  surround- 
ing soft  parts,   and    new-formed 
connective  tissue.    In  the  so-called 
true  aneurysm  the   vessel  dilates 
very    gradually,    as    a   result    of 
chronic   endarteritis,  and  accord- 
ing as  the  latter  involves  the  entire  circumference  of  the  artery  or  only 
a  portion  of  it,  a  cylindrical  (aneurysma  cylindricum)  or  spindle-shaped 
(aneurysma  fusiforme)  or  sacculated  (aneurysma  sacciforme)  aneurysm 


Fio.  325. — Aneurysma  arterio-veno.suni  of  the 
temporal  artery  and  vein  following  an  in- 
cised wound  received  twenty-live  years  be- 
fore (Czerny). 


534    INJURIES  AND  SURGICAL   DISEASES   OF  THE   SOFT   PARTS. 


develops  (Fig.  322).     Of  course,  there  are  many  transitions  between 
each  of  these  different  forms. 

Occasionally  an  aneurysm  communicates  with  an  adjoining  vein,  as 
was  formerly   not  uncommon    after    phlebotomy,  in    consequence    of 

simultaneous  injury  to  the  brachial 
artery  at  the  elbow.  An  aneurysm 
of  this  description  Yirchow  calls  an 
aneurysma  arterio  -  venosum.  This 
term  is  better  than  aneurysma  vari- 
cosum  or  varix  aneurysma-ticus.  The 
aneurysma  arterio-venosum  takes  the 
form  either  of  a  circumscribed,  sac- 
culated tumour,  as  illusti'ated  in  Figs. 
323  and  324,  or,  as  a  result  of  the 
communication  between  the  artery 
and  vein,  there  occur  marked  dis- 
turbances in  the  circulation,  with 
pulsating  dilatations  of  the  distant 
branches  of  both  artery  and  vein 
(Figs.  325,  326).  If  pressure  is  ap- 
plied to  the  point  of  communication 
between  the  artery  and  vein,  the  pul- 
sation in  the  dilated  and  tortuous 
vessels  ceases  and  they  collapse.  In 
the  extremities  the  arterio-venous 
aneurysm,  as  a  result  of  the  com- 
munication between  the  artery  and 
vein,  leads  to  circulatory  disturbances 
throughout  the  entire  limb,  and  to 
numerous  small  aneurysms  and  dila- 
tations of  the  veins  (varices),  as  in  a 
case  reported  by  Stromeyer  and 
Krause  (see  Fig.  32G). 
According  to  Bramann,  of  one  hundred  and  fifty-nine  eases  of 
arterio-venous  aneurysm,  one  hundred  arid  eight  were  due  to  an  injury, 
fifty-six  following  phlebotomy,  twenty -nine  gunshot  wounds,  five  con- 
tusions which  caused  no  internal  wound,  and  nine  were  spontaneous. 
In  only  four  instances  was  an  arterio-venous  aneurysm  congenital. 
An  arterio-venous  aneurysm  may  develop  spontaneous!}-  from  a  true 
aneurysm,  which  becomes  gradually  adherent  to  the  vein.  The  latter 
becomes  obliterated  at  the  point  of  contact,  or  the  aneurysm  breaks 
into  the  open  vein. 


Fig.  S26. — Aiieurysnia  arterio-venosum  of 
the  left  hand  and  forearm  of  a  man 
forty-five  yeaiv;  old,  which  had  devel- 
oped gradually  after  a  bite  on  the  hand 
received  in  his  seventh  year.  Is'unier- 
ous  sacculated  aneurysms  on  the  tlexor 
side  (5).  and  very  marked  varicose  en- 
largement of  the  veins  on  the  extensor 
side  {A). 


{^95.]        INFLAxMMATIONS  AND   DISEASES   OF   BLOOD-VESSELS. 


>35 


Aneurysma  Racemosum,  Anastomoticum,  or  Cirsoideum. — In  aneu- 
rysiua  raceiiio.^uui,  or  anastuiiioticuni,  or  cirsoideum  (arterial  racemose 
aiigeioma,  cirsoid  angeioma),  there  is  a  cirsoid  dilatation,  tortuosity,  and 
thickening  of  the  artery  throughout  its  entire  distribution,  forming  a 
convoluted  mass  of  enlarged 
arteries  (Fig.  327).  The  race- 
mose aneurysm  occurs  espe- 
cially upon  the  scalp,  is  for  the 
most  part  of  congenital  origin, 
and  belongs  more  to  the  true 
tumours,  and  hence  the  term 
angeioma  arteriale  racemosum 
is  more  appropriate.  Cirsoid 
aneurysm  is  rarely  acquired, 
in  ^vhich  case  it  may  result 
from  some  mechanical  injury. 
A  distinction  used  to  be  made 
between  cirsoid  aneurysm  (va- 
rix  arterialis)  and  the  aneu- 
rysma anastomoticum  (angeio- 
ma arterial  racemosum,  tumor 
vasculosus  arterialis).  The 
former  was  said  to  result  more 
from  a  diffuse  dilatation  of 
the  arterial  branches,  and 
eventually  of  the  capillaries 
and  veins ;  while  the  latter 
was  said  to  be  made  up  of  newly  formed  dilated  and  lengthened  arte- 
rial branches,  resembling  more  closely  a  tumour.  But  both  forms 
merge  into  one  another  to  such  an  extent  that  it  is  impossible  to  make 
any  distinction.  An  analogous  tumour  formation,  the  so-called  plexi- 
form  neuroma  (see  Tumours  of  Xerves),  occurs  in  the  nerves. 

Aneurysma  Dissecans. — The  aneurysma  dissecans  is  a  particular  kind 
oj  traumatic  aneurysm  resulting  from  rupture  of  the  intima  and  media 
with  preservation  of  the  adventitia.  It  occurs  especially  in  the  aorta 
and  small  cerebral  arteries.  The  blood  escapes  between  the  media  and 
adventitia  and  lifts  one  from  the  other. 

Occurrence  of  Aneurysms. — As  regards  the  occurrence  of  aneurysms, 
they  are  most  common  in  the  thoracic  aorta  (the  ascending  and  trans- 
verse portions),  appearing  next  in  order  of  frequency  in  the  popliteal, 
carotid,  subclavian,  innominate,  axillary  artery,  etc.  According  to  Liit- 
tich,  out  of  one  hundred  and  ninety-six  cases,  one  hundred  and  sixty- 


i 

Fig.  327. — Anorionia  arteriale  racemosum  of  the  art. 
angularis  and  frontalis  dext.  and  sinistr.  of  a 
man  twenty  years  old  (Bruns).  Ligation  of 
the  right  external  carotid  and  the  leftcommon 
carotid.     Death  from  cerebral  embolus. 


536    INJURIES  AND  SURGICAL  DISEASES  OP  THE  SOFT  PARTS. 

one  were  observed  in  men  and  only  thirty-four  in  women.  Aneurysms 
are  comparatively  connnon  in  England,  particularly  in  the  English 
army.  The  aneurysma  cirsoides  or  anastomoticum  is  observed  most 
frequently  in  the  common  iliac  and  on  the  scalp.  Of  aneurysms  in- 
volving the  small  arteries,  those  in  the  brain,  the  lungs  and  the  heart 
are  especially  important. 

The  Symptoms  and  Course  of  Aneurysms. — The  most  important  symp- 
toms of  an  aneurysm  are  brought  about  by  the  blood  flowing  into  the 
sack,  and  consist  in  the  presence  of  pulsation  and^  friction  sound.  If 
a  hand  is  placed  upon  the  tumour  it  will  be  felt  to  enlarge  synchro- 
nously with  the  apex  beat.  By  palpation  and  auscultation  the  friction 
sound  can  also  be  made  out ;  it  is  caused  by  the  blood  rubbing  against 
the  inner  wall  of  the  sac.  As  regards  diagnosis,  a  careful  distinction 
must  be  made  between  the  actual,  true  pulsation  of  an  aneurysm  and 
the  communicated  pulsation  which  results,  for  example,  from  a  tumour 
or  an  abscess  being  lifted  by  an  underlying  large  artery.  If  the  pulsa- 
tion is  communicated,  there  is  usually  only  a  rise  and  fall  in  one  direc- 
tion, and  the  tumour  does  not  expand  equally  in  all  directions,  as  is  the 
case  in  the  true  pulsation  of  an  aneurysm.  But  the  pulsation  of  aneu- 
rysms is  not  always  plain,  it  being  very  slight,  for  exainple,  in  those 
with  thick  walls.  If  the  afferent  artery  of  an  aneurysm  is  compressed 
the  pulsation  and  friction  sound  ceases.  Mention  should  be  made  of 
the  fact,  which  is  of  diagnostic  importance,  that  very  vascular  sai-co- 
mata  of  bone,  for  instance,  also  pulsate. 

When  an  aneurysm  has  once  formed,  the  local  dilatation  of  the 
lumen  of  the  artery  never  returns  to  the  normal  again,  but,  on  the 
contrary,  it  constantly  increases,  and  in  addition  the  wall  of  the  vessel 
becomes  steadily  thinner,  and  finally  the  sac  bursts,  leading  to  fatal 
haemorrhage,  especially  in  aneurysms  of  the  aorta,  the  brain  and  lungs, 
etc.  As  a  result  of  the  increasing  enlargement  of  the  sac,  the  sur- 
rounding parts  are  proportionately  displaced  and  the  bones  are  grad- 
ually more  or  less  eroded — for  example,  the  sternum,  the  vertebrae,  and 
ribs,  in  aneurysms  of  the  aorta.  Pressure  upon  adjoining  nerves  gives 
rise  to  corresponding  symptoms  (pain,  paralysis).  The  skin  resists 
comparatively  the  longest  time,  but  it  also  may  be  broken  through, 
causing  sudden  death  from  haemorrhage. 

Spontaneous  cure  of  an  aneurysm  by  filling  of  the  sack  with  a 
thrombus  and  by  change  of  the  latter  into  cicatricial  tissue  only  occurs 
in  the  case  of  smaller  aneurysms.  The  thrombi  originate  from  the 
slowing  of  the  current  and  the  pathological  changes  in  the  wall  of  the 
aneurysm. 

Extensive  thrombi  with  many  layers  also  develop  in  larger  aneu- 


=5  95.]       INFLAMMATIONS   AND   DISEASES  OF   BLOOD-VESSELS.  537 

rysms,  but  in  tliese  cases  complete  obliteration  of  the  aneurysmal  sac 
by  cicatricial  connective  tissue  does  not  take  place.  The  thrombus 
formation  sometimes  increases  to  such  an  extent  that  the  circulation  is 
interrupted,  and  gangrene,  possibly  of  the  entire  extremity,  takes  place. 
Occasionally  the  thrombi  soften  and  break  down,  giving  rise  to  embolic 
processes,  or  the  thrombi  may  become  calcified. 

Diagnosis  of  Aneurysms. — From  what  has  been  said,  it  follows  that 
the  diagnosis  of  aneurysm  is  not  difficult  as  long  as  we  have  to  deal 
with  cases  which  are  accessible  to  careful  examination.  As  regards 
diagnosis,  the  above-described  true  pulsation  and  the  friction  sound,  as 
well  as  their  disappearance  after  compression  of  the  affei-ent  artery,  are 
the  most  important  sym])tonis.  Nevertheless  good  surgeons  have 
made  errors  and  taken  aneurysms  for  abscesses,  particularly  in  cases 
where  there  are  manifestations  of  infiammation,  swelling  of  the  soft 
parts  around  the  aneurysm,  etc.  If  this  mistake  in  diagnosis  should 
occur,  and  the  aneurysm  be  incised,  resulting  in  a  gush  of  blood,  the 
incision  should  be  immediately  closed  by  placing  the  hand  upon  it,  the 
afferent  artery  compressed,  Esmarch's  rubber  tourniquet  applied,  and 
the  main  afferent  artery  immediately  ligated  in  its  continuity. 

On  the  other  hand,  it  may  happen  that  an  aneurysm  is  supposed  to 
be  present,  while  as  a  matter  of  fact  we  have  to  deal  with  a  very  vas- 
cular  tumour.  But  from  what  has  been  said  it  should  be  an  easy  mat- 
ter to  make  the  correct  diagnosis  in  such  cases. 

Prognosis  of  Aneurysms. — The  prognosis  of  aneurysms  varies  greatly, 
according  to  their  location.  In  general,  the  j^rognosis  of  aneurysms, 
as  far  as  spontaneous  cure  is  concerned,  is  unfavourable,  as  this  termi- 
nation is  only  possible  in  small  arteries  by  the  organisation  of  the 
thrombi,  calcification,  etc.  In  large  aneurysms  the  sack  constantly  in- 
creases in  size,  and  there  is  nothing  to  do  but  'check  the  enlargement 
of  the  aneurysm  by  proper  local  treatment,  and  possibly'^to  extirpate  it. 

Treatment  of  Aneurysms.— Mention  may  be  made  first  of  the  opera- 
tive  treatment  of  aneurysms.  The  oldest  method  of  operative  treat- 
ment is  that  of  Antyllus.  It  consists  in  splitting  open  and  extirpating 
the  sack  after  previously  performing  central  and  peripheral  ligation  of 
the  main  trunk  of  the  artery  and  any  branches  which  may  be  given  off 
from  tlie  aneurysm.  The  aneurysm  is  exposed  with  the  aid  of  Es- 
march's artificial  ischgemia  and  opened  by  incision.  After  removing 
the  clot  from  the  sack  a  probe  is  passed  into  the  afferent  and  efferent 
ends  of  the  artery,  and  both  are  closed  by  a  ligature.  After  this  all 
branches  given  off  at  any  point  from  the  wall  of  the  sac  must  be  tied. 
The  aneurysm  itself  can  then  be  extirpated,  or,  when  this  is  too  diffi- 
cult, a  portion  of  the  sack  may  be  left  behind.    The  performance  of  this 


U- 


538    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT  PARTS. 

operation  may  present  great  difficulties,  in  the  first  place,  on  account 
of  the  ninneroiis  branches  which  spring  from  the  wall  of  the  sack,  and 
then  because  the  central  and  peripheral  ends  of  the  arter\^  on  each  side 
of  the  aneurysm  may  be  so  thickened  that  it  may  be  very  difficult  to 
find  and  ligate  them.  Otlier  methods  of  operative  treatment  for  aneu- 
rysm consist  in  the  ligation  of  the  artery  on  the  central  or  peripheral 
side  of  the  aneurysm.  The  central  ligation  of  the  afferent  arterial 
trunk  is  either  performed  close  above  the  aneurysm  (Anel),  or  at  some 
distance  from  the  latter  at  the  so-called  place  of  election,  where  the 
artery  is  easily  accessible  (Hunter).  Ligation  of  the  artery  on  the 
peripheral  side  of  the  aneurysm  has  been  recommended  particularly 
by  Brasdor,  "Wardrop,  and  Desault.  The  formation  of  a  thrombus  in 
the  sack,  and  thus  its  diminution  in  size  by  the  development  of  cica- 
tricial tissue,  are  said  to  be  favoured  by  all  these  methods.  Their  suc- 
cess is  uncertain,  and,  particularly  after  ligation  of  the  afferent  artery, 
even  gangrene  has  been  observed  of  varying  extent  in  the  region  sup- 
plied by  the  artery.  Ligation  of  the  efferent  artery  is  especially  to  be 
recommended  when  ligation  of  the  afferent  vessel  is  impossiljle  or  too 
difficult ;  thus  in  aneurysm  of  the  innominate,  for  example,  one  would 
ligate  the  carotid  and  subclavian  arteries.  The  best  though  at  the 
same  time  the  most  difficult  method  is  that  of  Antyllus.  The  next, 
as  far  as  the  certainty  of  its  effect  is  concerned,  is  the  ligation  of  the 
afferent  arterial  trunk  close  above  the  aneurysm,  while  ligation  of  the 
efferent  artery  close  Ijelow  the  aneurysm  is  the  most  uncertain  pro- 
cedure. Af':er  ligation  of  the  afferent  artery  at  the  place  of  election 
in  Hunter's  method,  recurrence,  as  a  general  thing,  easily  takes  place ; 
nevertheless  this  method  is  of  value  for  the  reason  that  often  in  the 
neighbourhood  of  the  aneurysm  the  artery  is  the  seat  of  atheromatous 
disease,  which  makes  ligation  impossible. 

Of  the  other  methods  of  treatment  we  should  mention,  in  the  first 
place,  digital  and  instrumental  compression  of  the  afferent  artery, 
which  is  particularly  adapted  for  aneurysms  upon  the  extremities. 
This,  also,  is  for  the  purpose  of  exciting  a  coagulation  in  the  aneu- 
rysmal sac.  The  procedure  is  entirely  devoid  of  danger,  but  it  is  often 
so  painful  that  the  patient  cannot  endure  it  long  enough.  Sometimes 
even  gangrene  of  the  skin  may  occur  at  the  point  where  the  pressure 
is  applied.  The  procedure  must  as  a  general  thing  be  continued  for 
several  days,  and  it  is  best  for  the  compression  to  be  kept  the  same 
for  several  hours  (see  Fig.  79).  There  must  be  several  persons  who 
can  relieve  one  another  in  performing  digital  compression.  Special 
pads,  Esmarch's  elastic  bandage,  or  some  otlier  simple  instrument  such 
as  a  crutch  or  a  broomstick,  have  been  recommended  for  carrying  out 


^U'i.]        INFLAMMATIONS  AND   DISEASES  OF   BLOOD-VESSELS.         539 

instruineiital  compression.  Forced  flexion  of  the  extremity  has  also 
been  used  in  ])lace  of  instruments  (see  Fi<j^.  TO).  J'robably  the  most 
aiivantagcous  way  of  carrying  out  this  method  is  to  apply  an  elastic 
bandage  for  about  an  liour  and  a  half,  enveloping  the  affected  ex- 
tremity from  its  periphery  up  to  a  point  near  the  aneurysm  ;  then  an 
elastic  tourniquet  is  applied  around  the  extremity  in  the  neighbour- 
hood of  the  aneurysm  on  its  proximal  side,  and  after  the  lapse  of  about 
an  hour  and  a  half  the  bandage  and  tourniquet  are  removed,  and 
digital  or  instrumental  compression  is  employed  for  six  to  twelve 
hours.  Pearce  Gould  recommends  the  administration  of  dry  albu- 
minous food  and  large  doses  of  iodide  of  potassium  before  using  the 
elastic  compression,  in  order  to  increase  the  coagulability  of  the  blood. 

The  other  methods  of  treating  aneurysm  consist  in  exciting  a 
coagulation  of  the  blood  in  the  aneurysmal  sac  by  chemical  means — as 
by  the  injection  of  ergotin,  liq.  ferri  sesquichlorat.,  alcohol,  etc. — or  by 
foreign  bodies  (catgut,  silver,  steel  or  copper  wire,  horse-hair,  lami- 
naria),''  by  acupuncture,  and  by  electropuncture.  I  consider  any  treat- 
ment by  injection  dangerous,  and,  consequently,  not  to  be  recom- 
mended ;  especially  after  the  injection  of  liq.  ferri  sesquichlorat.,  exten- 
sive clotting  and  speedy  death  from  pulmonary  and  cerebral  emboli 
have  taken  place.  As  regards  the  results  obtained  by  the  introduction 
of  steel  or  copper  wire  (iilipuncture)  into  large  aneurysms,  as  Moore 
does  in  the  case  of  aortic  aneurysms,  the  recently  published  statistics  of 
Yerneuil  are  very  unfavourable.  Of  thirty-four  cases  treated  in  this 
way,  only  two  were  cured,  and  thirty  died  comparatively  soon  after  the 
operation.  Phillippe  obtained  satisfactory  results  in  dogs  by  the  intro- 
duction of  silver  or  copper  wire,  horse-hair,  laminaria,  etc.,  into  the 
femoral  or  carotid  artery.  I  have  obtained  very  remarkable  results  in 
aortic  aneurysms  by  means  of  galvano-puncture,  the  technique  of  which 
is  described  on  page  79,  and  also  in  the  Special  Surgery. 

The  best  treatment  for  the  cases  of  cirsoid  aneurysm  and  for 
arterio-venous  aneurysm  is  extirpation,  followed  by  careful  arrest  of  all 
bleeding  by  ligation  of  the  afferent  and  efferent  vessels.  In  angeioma 
arteriale  racemosum  (cirsoid  aneurysm)  ligation  of  the  main  afferent 
artery  is  to  be  recommended  ;  or  igni puncture  may  be  performed  with 
the  galvano-cautery  or  with  the  fine  point  of  the  Paquelin  instrumefiit. 

The  treatment  of  ordinary  aneurysms  of  course  varies  greatly  with 
their  location.  In  general  it  follows,  from  what  has  been  said,  that, 
whenever  it  is  possible,  compression  should  be  tried  first,  alternating 
elastic  bandaging  with  digital  compression  or  compression  by  means  of 
a  stick.  If  this  compression  treatment  is  borne  it  can  be  continued 
for  a  long  time ;  Billroth  has  kept  it  up  for  months,    Not  infrequently 


540    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 


compression  proves  successful  after  the  lapse  of  months.  If  compres- 
sion cannot  be  carried  out  or  is  not  successful,  an  operation,  when  pos- 
sible, should  be  undertaken,  the  best  being  that  of  Antyllus,  or,  if  the 
latter  cannot  be  used,  Anel's,  Hunter's,  or  Brosdor's  operation  should 
be  pei-formed  in  the  manner  described  above.  4- 

Varices. — By  varix  is  understood  a  dilatation  of  the  wall  of  a  vein 
(Fig.  828j.     This  originates  for  the  most  part 'from  mechanical  inter- 

,  ference  with  the  return  flow  from  the 
veins,  and,  consequently,  occurs  in  local 
or  general  stasis,  such  as  tliat  due  to  the 
presence  of  tumours,  particularly  in  the 
abdomen,  or  to  pregnancy ;  or  it  is  due 
'■  to  cardiac  weakness,  obstruction  to  the 
entrance  of  venous  blood  into  the  heart, 
etc.  The  greater  the  resistance,  the 
greater  will  Ije  the  pressure  under  which 
the  blood  flows  in  the  veins,  and  so  much 
the  sooner  will  the  walls  of  the  veins  be- 
come stretched.  The  origin  of  varices 
is  favoured  by  pathological  changes  in 
the  walls  of  the  veins  and  in  the  parts 
surrounding  them.  Occasionally  an  in- 
herited disposition  towards  varices  must 
be  acknowledged.  In  predisposed  indi- 
viduals with  flabby  veins,  comparatively 
slight  causes  may  suffice  to  excite  va- 
rices. Thus  varices  are  produced  in  the 
lower  extremities,  for  example,  of  in- 
dividuals whose  occupation  compels  them  to  stand  a  great  deal. 

Occurrence  of  "Varices. — As  regards  the  occurrence  of  varices,  they 
are  ])articularly  a])t  to  be  found  in  parts  of  the  body  where  the  return 
flow  of  blood  in  the  veins  is  rendered  difficult,  and  consequently  they 
are  common  in  the  lower  extremities,  at  the  anus  (hsemorrhoids),  in  the 
scrotum,  and  in  the  spermatic  cord  (varicocele).  Women  suffer  from 
varices  more  commonly  than  men,  probably,  in  the  main,  as  a  result 
of  ]^regnancy. 

Symptoms  of  Varices. — One  finds  that  especially  the  veins  of  the  skin, 
and  also  the  dee})er  veins  of  a  larger  or  smaller  area,  are  dilated  evenly, 
or  in  the  form  of  sacs  or  spindles,  and  are  tortuous  and  lengthened 
(Fig.  326,  a,  and  Fig.  328).  Blue,  sacculated,  tortuous  bands  and  con- 
volutions are  seen,  varying  in  size,  over  which  the  skin  is  usually  more 
or  less  thinned.     Not  infrequently,  as  a  result  of  rupture  of  these  var- 


FiG.  828. — Varicose  ulcer  of  the  lecf  (a), 
resulting;  from  varicose  veins. 


^•05.]        INFLAMMATIONS   AND   DISEASES  OF  BLOOD-VESSELS.         54I 

ices  and  the  ovei-lyiiii^  skin,  secondary  lutein orrliages  take  place  which, 
in  the  lower  extroniity,  for  instance,  may  canse  death  if  not  promj^tly 
arrested ;  under  these  conditions  a  spontaneous  arrest  does  not  easily 
occur.  Sometimes  periphlebitic  inflammation  and  suppuration  origi- 
nate in  the  parts  surrounding  tlie  varices,  possibly  in  conjunction  with 
an  eczema  or  ulcer  in  the  skin.  Thrombi  are  also  observed  in  varices 
as  a  result  of  retardation  of  the  blood  current  in  the  dilated  vessels, 
just  as  in  aneurysmal  sacks.  They  may  or  may  not  become' organised. 
Soften  and  break  down,  or  become  calcified.  If  they  become  calcified, 
the  so-called  vein  stones  or  phleboliths  result.  AVhen  thrombi  form, 
the  dilated  veins  are  plainly  to  be  felt  as  firm,  hard  cords.  Suppurative 
l)reaking  down  of  the  thrombi  is  observed,  for  example,  in  conjunction 
with  an  ulcer  of  the  leg  or  eczema  which  has  not  been  treated  antisep- 
tically.  In  this  condition  there  is  danger  of  the  development  of  em- 
bolic processes  and  pyaemia  from  the  carrying  off  of  the  suppurating 
clots  into  the  general  circulation.  It  is  a  matter  of  great  practical 
importance  that  wherever  varices  exist  there  is  a  tendency  towards 
inflanimatory  processes,  with  increased  transudation  and  cellular  infil- 
ti-ation.  Hence  it  is  clear  why  the  development  of  vesicles  and  ecze- 
mas which  break  down  and  ulcerate  are  so  common  upon  lower  extrem- 
ities where  there  are  varices.  Should  a  small  injury  be  received,  there 
is,  for  the  same  reasons,  only  a  slight  tendency  towards  repair,  and  an 
ulcer  may  readily  result.  The  ulcers  of  the  leg,  which  are  so  common, 
are  usually  observed  in  conjunction  with  varicosities,  and  so  are  cor- 
rectly designated  varicose  ulcers  of  the  leg  (Fig.  328).  In  such  cases 
there  usually  exists  a  pronounced  infiammatory  condition  in  the  lower 
extremity,  with  hyperplasia,  extensive  oedema,  and,  in  severe  cases,  a 
deforming  of  the  foot  and  leg  by  an  induration  resembling  elephan- 
tiasis. 

The  diagnosis  and  prognosis  of  varices  may  be  inferred  from  what 
has  just  been  said. 

Treatment  of  Varices. — The  treatment  of  varices  varies  with  their 
cause  and  location.  I  must  refer  the  reader  to  my  Special  Surgery  for 
the  detailed  description  of  the  treatment  for  varices  of  special  localities 
— such  as  the  leg,  the  rectum  (haemorrhoids),  etc.  Only  the  follov.-ijig 
brief  statements  can  be  given  here :  In  the  first  place,  varices  can  be 
cured  by  operative  measures — such  as  extirpation  after  previously  ap- 
plying a  catgut  ligature,  or  by  cauterisation  with  the  galvano  or  Paque- 
lin  cautery,  as  in  the  case  of  haemorrhoids.  In  severe  cases  Madelung 
has  had  good  results  from  removal  of  the  varices,  in  the  lower  extrem- 
ity, for  example,  by  the  following  method  :  By  allowing  the  leg  to  hang 
down  from  the  operating  table  the  varices  are  caused  to  become  promi- 


jL 


542    INJURIES   AND   SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

nent ;  thin  rubber  tubing  is  tied  around  the  upper  tliird  of  the  thigli, 
loosely  enough  not  to  compress  the  artery.  The  skin  is  divided  by  a 
longitudinal  incision  along  the  entire  length  of  the  varicose  vein,  and 
freed  on  both  sides  of  the  incision.  The  proximal  portion  of  the  vein 
— generally  the  saphenous — is  secured  by  a  double  ligature,  and  the 
vein,  with  its  ramifications,  is  removed  from  above  downwards,  without 
using  the  edge  of  the  knife.  The  branches  are  seized  by  artery  clamps 
and  ligated.  Percutaneous  ligation  {Umstechnruj)  of  the  veins  has  also 
been  recommended ;  a  catgut  ligature  is  carried  on  a  curved  needle 
under  the  vein  and  knotted  on  the  skin,  possibly  over  a  drainage-tube,. 
Even  after  extirpation  of  the  varices  recurrences  are  rather  common. 
In  extensive  varices  involving,  for  example,  the  subclavian  vein  and  its 
branches,  I  can  recommend  a  very  simple  and  effective  method,  namely, 
ignipuncture — i.  e.,  puncturing  the  varicose  venous  trunks  with  the 
galvano-cautery,  or  with  the  fine  point  of  the  Paquelin  cautery.  A 
protective  dressing  is  ordinarily  unnecessary,  or,  at  the  most,  only  for 
twenty-four  hours.  The  puncture  wounds  dry  and  are  covered  by 
small  scabs,  which  fall  off  after  a  time. 

Ligation  of  the  vena  saphena  magna  is  perhaps  the  best  treatment 
for  the  varices  of  the  leg  which  are  so  common  ('Trendelenburg).  Tren- 
delenburg has  practised  this  simple  operation  for  years  ^vith  the  best 
results.  Its  success  is  very  surprising.  Varicose  ulcers  of  the  leg  also 
heal  with  remarkable  rapidity. 

The  bjoodless  methods  of  treatment  are,  for  the  most  part,  only 
palliative  in  their  nature.  In  the  varices  of  the  leg,  for  example,  they 
consist  mainly  in  the  use  of  dressings  which  exert  pressure,  particularly 
laced  stockings,  or  roller  and  elastic  bandages.  In  general,  Martin's 
cheap  elastic  bandage  is  preferable  to  the  elastic  stocking.  If  ulcers 
of  the  leg  are  present,  they  should  be  dusted  with  iodoform,  dermatol, 
bismuth,  or  oxide  of  zinc,  and  over  this  dres.sing  Martin's  elastic  band- 
age should  be  applied.  With  these  bandages- the  patient  can  attend  to 
his  business.  The  bandages  are  taken  off  in  the  evening,  thoroughly 
washed  in  water,  and  dried  during  the  night.  The  greatest  cleanliness 
is  necessary  in  this  method  of  treatment.  Oftentimes  the  elastic  band- 
age is  not  borne  well,  as  it  causes  an  eczema.  In  this  case  the  rubber 
bandage  should  be  left  off  and  the  eczema  treated  with  some  ointment 
and  dusted  with  starch,  or  starch  and  zinc  oxide  (5  to  10  :  1),  over 
which  a  cotton  dressing  is  placed.  In  varices  of  the  lower  extremity, 
Landerer  recommends  compression  of  the  internal  saphenous  vein  by 
a  truss  consisting  of  a  spring  made  in  the  shape  of  a  parabola,  and  a 
pad  filled  with  water ;  this  is  worn  above  or  below  the  knee. 

Finally,  mention  should  be  made  of  the  injection  of  drugs  into  the 


^!)6.]  THE    DISEASES  OF   THE   LYMPH ATU;   SYSTEM.  543 

parts  which  surroinul  the  veins.  Paul  Vogt  recoinineiuls  cutaneous 
and  subcutaneous  injections  of  ergotin  into  the  perivascular  tissues. 
If  this  method  is  employed,  as  fresh  solutions  of  ergotin  as  possible 
should  be  used' (extract,  secal.  cornut.,  AYernich,  1  to  10  aq.  destil.), 
to  which  it  is  a  good  plan  to  add  a  little  carl)olic  acid  (O'lO)  to  prevent 
decomposition.  It  is  wise  not  to  permit  the  solution  to  stand  for  too 
long  a  time,  but  to  renew  it  frequently.  The  solution  is  injected  by  a 
hypodermic  syringe  and  the  small  punctured  wound  closed  by  iodo- 
form collodion.  If  an  abscess  should  result,  it  must  be  promptly  in- 
cised. Injections  of  absolute  alcohol,  or  of  a  few  drops  of  concentrated 
carbolic  acid,  as  in  hfemorrhoids,  are  better  than  ergotin  (Lange). 
Care  must  always  be  taken  to  avoid  any  direct  injury  to  the  vein  and 
to  make  the  injections  only  into  the  perivascular  tissues.  ^ 

§  96.  The  Diseases  of  the  Lymphatic  System. — The  acute  and  chronic 
inflammations  of  the  lymph  vessels  and  glands  have  been  sufficiently 
described  under  the  subjects  of  inflammation  (§§  56  to  58),  acute  lym- 
phangitis and  lymphadenitis  (§  68),  tul)erculosis,  scrofula,  syphilis,  etc. 
We  shall  return  to  tumours  of  the  lymph  glands  in  the  chapters  on 
New  Growths, 

There  only  remains  to  be  briefly  discussed  here  lympliangeiectasise 
and  lymph  fistulre  with  lymphorrhoea  or  lymphorrhagia. 

Lymphangeiectasise. — Dilatation  of  the  lymphatic  vessels  (13'mphan- 
geiectasis),  from  obstruction  to  the  return  flow  of  lymph,  occurs  under 
conditions  similar  to  those  which  are  present  in  dilatation  of  the  veins. 
Lymphangeiectasise  are  not  infrequently  observed  as  a  result  of  recur- 
rent attacks  of  hypememia  and  inflammations  of  various  kinds.  The 
liyperplasia  of  the  skin  and  subcutaneous  tissue  occurring  in  conjunc- 
tion with  frequently  repeated  inflammations,  and  which  is  called  ele- 
phantiasis, is  in  the  main  a  true  lymphangeiectasis  (see  §  93).  But, 
as  a  general  thing,  the  return  flow  of  lymph  has  so  many  channels 
through  which  it  can  pass  that  if  stasis  occurs  compensation  readily 
takes  place,  and  for  this  reason  an  occlusion  even  of  the  thoracic 
duct  may  cause  no  serious  trouble.  Lymphangeiectasiag  are  observed 
most  commonly  in  the  lacteal  vessels  of  the  mesentery.  In  rare  cases, 
as  a  result  of  some  traumatism,  there  occasionally  develop  circum- 
scribed subcutaneous  or  interstitial  collections  of  lymph — so-called 
lymph  extravasations  or  lymph  cysts  similar  to  the  hsematomata  de- 
rived from  the  blood-vessels. 

As  regards  the  symptoms  which  lymphangeiectasise  give  rise  to,  it 
should  be  briefly  stated  that  in  lymphangeiectasise  of  the  skin  the  latter 
is  filled  with  dilated,  tortuous  lymph  vessels ;  the  skin  for  this  reason 
has  a  nodular  appearance ;  it  is  covered  with  vesicles,  and  frequently, 


544-  INJURIES  AND  SURGICAL  DISEASES   OF  THE  SOFT   PARTS. 

as  a  result  of  hyperplasia  of  the  tissues,  comes  to  resemble  elephantiasis. 
If  the  varices  of  the  lymphatic  network  in  the  cutis  are  more  pro- 
nounced, vesicles  of  different  size  develop.  Not  infrequently  the  vari- 
cose lymphatic  vessels  burst  and  give  rise  to  a  so-called  lymph  fistula. 
Gjeorgewic  states  that  in  fifty-five  cases  lymphorrluea  was  observed 
twenty-two  times  in  consequence  of  the  spontaneous  bursting  of  the 
varicose  lymph  vessels.  The  lymph  usually  exudes  from  one  or  more 
vesicles  and  sometimes  from  between  the  epithelial  cells,  as  in  one  case 
which  I  saw,  without  an  actual  fistula  being  visible.  Under  these  cir- 
cumstances, the  escape  of  lymph,  the  lymphorrhagia  or  lymphorrhd-a 
may  be  very  considerable.  In  one  case  of  lymphangeiectasis  of  the  labia 
majora  in  which  a  fistula  developed,  Kieden  found  that  in  four  hours 
there  was  an  escape  of  one  and  a  half  litre  of  a  milky,  slightly  yellow- 
ish liquid  containing  fat  and  resembling  chyle.  The  most  serious 
lymphorrhagia  is  that  which  results  fi-om  a  rupture  of  the  thoracic 
duct  caused,  for  instance,  by  a  traumatism  or  by  an  advanced  degree 
of  stasis,  possibly  from  closure  of  its  lumen  by  inflammation  or  a  tumour 
in  its  neighbourhood.  In  such  instances  there  is  a  great  accumulation 
of  lymph  in  the  thoracic  and  abdominal  cavities  (chylous  hydrothorax 
and  chylous  ascites),  which  will  be  described  in  the  Special  Surgery. 

In  the  rare  cases  of  circumscribed,  subcutaneous,  and  interstitial 
collections  of  lymph  which,  as  a  result  of  a  traumatism,  for  example, 
has  escaped  from  the  vessels,  there  develops  a  fluctuating,  circum- 
scribed swelling  which  at  the  outset  grows  rapidly  and  then  usually  re- 
mains stationary  (lymph  cysts).  Should  the  extravasation  of  lymph 
contiime,  a  lymph  fistula  may  eventually  form  from  a  rupture  of  the 
skin. 

The  microscopic  changes  in  lymphangeiectasise  of  the  skin  consist 
principally  in  the  development  of  numerous  irregularly  shaped,  com- 
plex cavities,  lying  in  and  close  beneath  the  papillary  layer  of  the  cutis 
and,  in  fact,  directly  beneath  the  epidermis,  which  are  lined  with  endo- 
thelium and  communicate  with  the  plexus  of  lymphatic  vessels.  Not 
infrequently  lymphatic  vessels  with  hypertrophic  walls  are  found  in 
the  deepest  layers  of  the  cutis  and  subcutaneous  cellular  tissue. 

Congenital  Lymphangeiectasis. — The  lymphangeiectasis  is  sometimes 
congenital,  particularly  in  the  tongue  and  lips  (macroglossia,  macro- 
cheilia  lymphangeiectatica),  and  also  in  the  skin  of  the  scrotum  and 
labia  pudendi. 

Treatment  of  Lymphangeiectasis,  Extravasations  of  Lymph  (L3nnpli 
Cysts  and  Lymph  Fistulae). — The  treatment  of  lymphangeiectasite  is  in 
general  the  same  as  for  varicose  veins,  and  often  enough  it  is  unsuc- 
cessful.     In   many    cases   cauterisation    with   the   fine   point   of   the 


§97.]  TIIK   DISEASES  OF  THE   PERIPHERAL  NERVES.  545 

Paquelin  or  galvano-cautery  renders  excellent  service.  Successful  ex- 
tirpation may  prove  very  difficult  for  the  reason  that  the  boundary  be- 
tween the  diseased  and  healthy  tissues  is  so  hard  to  recof]^nise.  For 
lymph  cysts  compression  should  be  tried,  and  if  this  fails,  "the  sack 
should  be  laid  open  witli  or  without  cauterisation  of  its  walls  with 
a  three-  to  Hve-per-cent.  solution  of  carbolic  acid.  Lymph  fistula? 
have  been  cured  by  transverse  division  of  the  skin  on  the  proximal  side 
of  the  fistula.  As  regards  the  treatment  of  elephantiasis,  injuries  of 
tlie  thoracic  duct,  and  congenital  lymphangeiectasiae,  I  must  refer  the 
reader  to  my  Special  Surgery.    / 

§  97.  The  Diseases  of  the  Peripheral  Nerves. — "We  sliall  confine  our- 
selves here  only  to  the  surgical  aspects  of  diseases  of  the  nerves — i.  e., 
we  shall  only  take  up  those  wliich  are  capable  of  surgical  treatment. 
We  have  already,  in  a  previous  chapter,  discussed  the  most  important 
diseases  of  the  peripheral  nerves.  Degeneration  and  regeneration  of 
nerves,  following  contusion  or  division  of  them,  has  been  described  in 
§§87  and  88,  where  the  sequelae  of  injuries  to  nerves,  the  paralyses, 
and  the  vasomotor  and  trophic  disturbances  have  been  discussed. 
Trismus  and  tetanus  have  been  described  under  the  subject  of  Infec- 
tious Diseases  of  AVounds  (§  73),  and  the  symptoms  of  shock  in  conse- 
quence of  injury  to  the  sensory  nerves  in  ^  63.  Inflammation  of  the 
peripheral  nerves  (neuritis)  has  been  described  in  connection  with  in- 
juries of  nerves  (§87),  but  the  subject  must  be  briefly  reviewed  at  this 
place. 

Neuritis. — Xeuritis  occurs  in  an  acute  and  chronic  form.  The 
most  common  causes  of  neuritis  are  injuries  of  various  kinds,  cold, 
inflammations  of  neighbouring  organs,  and  acute  or  chronic  constitu- 
tional diseases,  such  as  typhoid  fever,  the  acute  exanthemata,  diph- 
theria, syphilis,  leprosy,  chronic  alcoholism,  etc.  Often  enough  no 
definite  cause  for  the  neuritis  can  be  demonstrated. 

Anatomically,  acute  neuritis  is  characterised  by  redness  and  swell- 
ing and  generally  by  a  serous,  or  sero-fibrinous  or  purulent  exudation 
between  the  bundles  of  nerve  fibres.  Microscopically,  in  addition  to 
the  above-mentioned  manifestations  of  hyperaemia  and  inflammatory 
exudation  there  is  found  a  commencing  degeneration  of  the  medullary 
sheath  and  axis  cylinder  of  the  nerve  fibres,  and  a  proliferation  of  the 
nuclei  in  the  sheath  of  Schwann.  Occasionally  the  nerve  perishes 
more  or  less  completely  from  suppuration  or  gangrene.  In  chronic 
neuritis  there  is  partly  a  new  formation  of  connective  tissue,  an  indura- 
tion and  sclerosis  of  the  nerve,  and  partly  a  degeneration  of  the  nerve 
substance.  In  a  man  dying  from  alcoholism  Eichhorst  found  a  pe- 
culiar degenerative  atrophy  of  the  peripheral  nerve  fibres  without  con- 
35 


546    INJURIES   AND  SURGICAL   DISEASES  OP   THE   SOFT    PARTS. 

nective-tissue  growtli  (neuritis  fascians)  ;  there  was  also  a  cori'espond- 
ing  atrophy  of  the  muscles. 

The  symptoms  of  neuritis,  as  far  as  they  concern  the  surgeon,  have 
been  described  in  §  87,  under  Injuries  of  Nerves.  For  further  par- 
ticulars we  must  refer  the  reader  to  the  text  books  on  the  patliology  of 
nerves.  Wa  have  remarked  before  that  neuritis  gradually  extends  in 
the  form  of  an  ascending  and  descending  neuritis  and  gives  rise  to  cor- 
responding disturbances.  The  treatment  of  neuritis  depends  upon  the 
cause.  In  the  main,- the  surgeon  has  to  deal  with  injuries  to  nerves,  of 
which  the  therapy  has  been  given  in  §  88. 

Multiple  Neuritis.— Particular  interest  attaches  to  multiple  neuritis,  in 
the  study  of  which  Leyclen  has  won  great  credit.  He  distinguishes  the  fol- 
lowing forms  :  1.  The  infectious  form  :  paralyses  following  diphtheria, 
typhoid,  and  other  infectious  diseases,  multiple  neuritis  in  syphilis  and  tuber- 
culosis. 2.  The  toxic  form  of  multiple  neuritis  (lead,  arsenic,  and  phosphor- 
ous paralysis,  paralyses  following  CO  and  uS  poisoning,  ergotism,  mercurial 
paralyses,  alcoholic  neuritis).  3.  Spontaneous  multiple  neuritis  following 
over-exertion,  exposure  to  unusual  cold,  etc.  4.  The  atrophic  (dyscrasic, 
cachectic)  form  following  anaemia  (pernicious  anaemia),  chlorosis,  mai'asnms, 
cancerous  cachexia,  diabetes,  and  tuberculosis.  .5.  The  sensory  neuritis,  pseu- 
do-tabes, ueuro-tabes  peripherica  :  a,  the  sensory  form  of  multiple  neurites; 
6,  the  sensory  neuritis  of  tabes.  The  pathogenesis,  course,  and  treatment 
will  be  found  iu  the  text  books  on  nervous  diseases. 

The  relationship  of  the  nervous  system  to  diseases  of  the  skin  has 
been  l)riefly  stated  in  §  93,  and  we  shall  return  to  the  subject  of  neuro- 
pathic bone  and  joint  affections  under  Diseases  of  Joints.  New 
growths  of  nerves  are  described  under  the  subject  of  Tumours. 

Traumatic  Neurosis.  —  The  so-called  traumatic  neurosis  (railway 
spine)  is  the  result  of  concussion  of  the  brain  and  spinal  cord  following 
a  fall,  a  railroad  accident,  a  severe  contusion,  a  blow,  etc.,  and  is  of 
great  clinical  interest.  Patients  of  this  kind  are  often  erroneously 
thought  to  be  malingerers.  We  shall  have  to  confine  ourselves  here  to 
a  very  brief  description  of  this  disease.  The  course  of  the  disease  is 
somewhat  as  follows :  Immediately  after  the  accident  there  will  often 
be  symptoms  of  shock  with  marked  depression.  Then  gradually  a 
permanent  or  only  temporary  improvement  begins.  In  the  most  un- 
favourable cases  there  will  be  observed  later  on  disturbances  of  various 
kinds,  particularly  manifestations  of  irritation,  and  certain  symptoms 
coming  on  in  attacks,  such  as  marked  excitement,  pains,  over-sensitive- 
ness of  the  special  senses,  impairment  of  voluntary  movements,  loss  of 
memory,  sometimes  anjesthesia  and  sometimes  hypersesthesia,  cramps, 
paralyses,  etc.  According  to  Forster  and  Konig,  there  is  an  objective 
symptom  in  traumatic  neurosis  consisting  in  a  peculiar  form  of  limita- 


^!)7.]  THE   DISEASES   OP   THE    PERIPHERAL   NERVES.  547 

tion  of  the  licld  of  vision  ;  a  test  ol)ject  carriiMl  ii\  a  (•entri petal  direc- 
tion from  the  |)ei-ij)hery  to  the  centre  of  the  field  of  vision  is  seen 
further  peripherally  than  when  the  object  is  carried  in  the  reverse 
direction — from  the  centre  towards  the  periphery.  Alhin  Hoffmann 
has  ri<:!;litly  directed  attention  to  tlie  fact  that  traumatic  neuroses  liave 
become  much  more  common  since  accident  insui-ance  has  been  intro- 
duced, and  that  it  occurs  mucli  less  often  as  an  actual  disease  in  people 
wlio  have  previously  been  perfectly  healthy  than  has  hitherto  been 
supposed.  Accident  insurance  has  directly  increased  malingering  and 
traumatic  hysteria.  As  a  matter  of  fact,  in  the  majority  of  cases,  we 
have  to  deal  with  a  psychosis  or  neurosis  whicli  is  not  based  upon  any 
anatomical  changes  in  the  central  nervous  system — in  other  words,  a 
hysteria,  as  Striimpell  and  Charcot  and  his  followers  have  rightly  em- 
phasised. But  in  a  small  number  of  severe  cases  there  are  actually 
progressive  anatomical  changes  in  the  central  nervous  system  which 
result  from  the  concussion  it  lias  sustained.  The  prognosis  of  a  pro- 
nounced traumatic  neurosis  is  often  very  unfavourable,  as  chronic  ill 
health  may  easily  result.  The  treatment  of  the  traumatic  neuroses  is  a 
subject  that  belongs  to  neuro-pathology. 

Neuralgia. — ]^y  neuralgia  (from  vevpov  and  dXyo^)  is  understood  a 
disease  of  the  sensory  nerves  the  chief  symptom  of  which  is  pain.  The 
pain  is  usually  localised  in  a  particular  nerve,  is  of  considerable  inten- 
sity, and  is  generally  intermittent  or  remittent.  The  neuralgias  belong 
to  the  most  common  neuroses,  and  their  causes  are  very  numerous. 
There  often  exists  a  pronounced  neuropathic  disposition.  Of  the  most 
common  causes  there  may  be  mentioned  in  particular  traumatic  and 
mechanical  influences,  intlammations,  compression,  disturbances  of  cir- 
culation, also  taking  cold,  infections  like  syphilis,  malaria,  poisoning 
by  lead  or  mercury,  and  finally  diseases  of  the  central  nervous  system, 
etc.  Gussenbauer  has  directed  attention  to  the  fact  that  habitual  con- 
stipation is  a  comparatively  frequent  cause  of  trigeminal  neuralgia, 
and  I  can  confirm  his  experiences  throughout.  The  pain  usually  comes 
on  in  attacks  of  varying  intensity  and  duration.  The  course  of  the 
neuralgias  is  sometimes  acute — a  few  days  or  a  week — and  sometimes 
chronic,  extending  over  weeks,  months,  or  years.  A  large  number  of 
the  cases  are  incurable,  and  last  throughout  the  rest  of  life.  Neural- 
gias of  the  trigeminus,  the  sciatic  and  intercostal  nerves  are  particu- 
larly common. 

Treatment  of  Neuralgia. — The  treatment  of  neuralgia  requires  first 
of  all  that  the  cause  of  the  disease  should  be  determined  by  a  careful 
examination  of  the  patient.  By  overcoming  habitual  constipation, 
anaemia,  affections  of  the  genital  apparatus,  especially  in  women,  etc., 


548    INJURIES  AND   SURGICAL  DISEASES   OF   THE  SOFT   PARTS. 

surprising   cures   of  long-standing  reflex  neuralgias  have  often  been 
brought  about. 

The  forms  of  treatment  of  neuralgia  itself  are  very  numerous,  and 
include  particularly  the  use  of  electricity,  narcotics  (morphine,  atro- 
pine), especially  in  the  form  of  subcutaneous  injections,  and  various 
drugs,  such  as  chloroform,  ether,  nitrite  of  amyl,  and  chloral  hydrate;' 
also  the  internal  administration  of  arsenic,  quinine,  preparations  of 
iron,  bromide  of  potassium,  iodide  of  potassium,  strychnine,  and  sur- 
gical measures,  particularly  massage,  nerve-stretching,  nerve  division 
(neurotomy),  resection  of  a  greater  or  less  portion  of  a  nerve  (neu- 
rectomy), or  extraction  of  the  affected  nerve  trunk  (Thiersch).  Elec- 
tricity is  sometimes  very  effective,  especially  the  galvanic  current.  In 
addition  to  the  above-mentioned  remedies,  counter-irritation  of  the 
skin,  powerful  electrical  stimulation,  vesicants,  the  red-hot  iron,  etc., 
may  be  tried.  In  suitable  cases  there  is  great  advantage  in  sea-bath- 
ing or  in  hot  springs  (Gastein,  Schlangenbad,  Pfaffers,  Ragatz,  AVild- 
bad,  AViesbaden,  Tephtz,  Leuk,  etc.),  or  in  cold-water  cures,  grape  cures, 
and  particularly  in  mountain  life  with  proper  exercise.  Massage  is 
often  very  successful. 

Neurectomy  and  Extraction  of  the  Nerves. — The  surgical  or  operative 
treatment  of  neuralgia  by  neurectomy  or  extraction  of  the  diseased 
nerves  only  succeeds  when  the  neuralgia  is  dependent  upon  a  peripheral 
cause.  But  even  in  such  cases  recurrences  often  occur,  although  no 
reunion  of  the  divided  nerve  has  followed  the  operation.  After  ex- 
traction of  the  affected  nerve,  the  collateral  branches  which  have  been 
left  intact  may  give  rise  to  a  recurrence,  and  permanent  cures  after 
neurectomy  are  rare,  as  is  shown  by  the  recent  statistics  of  Conrad 
taken  from  the  clinic  at  Bonn.  Operations  were  performed  ten  to 
fifteen  times  for  facial  neuralgia,  for  example,  without  a  single  per- 
manent cure. 

The  technique  of  neurectomy  and  of  extraction  of  the  diseased 
nerves  is  described  in  the  Special  Surgery. 

Nerve-stretching. — Xerve-stretching  was  first  practised  by  Billroth 
and  Xussbaum  for  chronic  affections  of  the  nerves,  for  epileptiform 
attacksj  and  for  neuralgias,  and  has  been  employed  witli  greatly  vary- 
ing success  for  sciatica,  tabes,  and  other  nervous  diseases.  The  opera- 
tion is  performed  by  exposing  and  isolating  the  sciatic  nerve,  for  in- 
stance, above  the  popliteal  space  or  higher  up  at  the  lower  border  of 
the  gluti]eus  maximus,  and  having  grasped  the  nerve  with  the  thumb 
and  index-finger,  it  is  stretched  by  a  vigorous  pull  until  it  has  be- 
come plainly  lengthened.  Xerve-stretching  is  only  indicated  in  diseases 
of  the  peripheral  nerves  and  not  in  affections  of  the  central  nervous 


J5!)8.] 


TnE   DISEASES  OF    MUSCLES.  54-9 


system.  The  effects  of  nerve-stretoliing  are  ])rul)al»ly  due  to  the  pro- 
duction of  an  acute  traumatic  inflammation  of  the  parts  surroundin<; 
the  exposed  nerve,  by  which  pathological  conditions,  such  as  degenera- 
ti.ve  processes,  adhesions,  etc.,  are  improved.  In  cases  of  spasm  of 
the  facial  nerve,  and  in  severe  cases  of  long-standing  sciatica,  I  have 
practised  nerve-stretcliing  with  good  results. 

Bloodless  Stretching  of  the  Sciatic— For  neuralgia  of  the  sciatic 
nerve  (sciat^a)  it  is  an  excellent  plan  to  employ  bloodless  stretching 
by  extreme  flexion  of  the  straightened  leg  at  the  hip  joint,  combined 

with  massage. 

§  98.  The  Diseases  of  Muscles,  Tendons,  and  Tendon  Sheaths. — In- 
flanimation  of  mu.-.cles  (mvu^itis)  originates  nio>t  commonly  fruin  trau- 
matisms, and  secondarily  from  inflammation  of  the  immediately  adjoin- 
ing parts  as  a  result  of  disturbances  of  circulation,  or  in  the  course 
of^infectious  bacterial  diseases  (pysemia,  typhoid,  glanders,  etc.j.  The- 
inflammatory  process  in  the  muscle  is  localised  principally  in  the  con- 
nective tissue  lying  between  the  primitive  muscular  fasciculi,  in  the- 
]>erimvsium  internum,  and  causes  secondary  changes  in  the  contractile 
muscular  substance.  In  other  cases  the  latter  is  primarily  the  seat,  for 
instance,  of  atrophy  and  degeneration,  and  the  changes  in  the  inter- 
muscular connective  tissue  are  secondary. 

Inflammatory  Muscular  Contracture.— Apart  from  the  local  inflam- 
matory disturbances  occurring  in  the  various  forms  of  myositis,  con- 
tracttire  of  the  inflamed  muscle  is  one  of  the  most  important  manifes- 
tations. We  shall  discuss  the  subject  of  contractures  more  fully  later  on, 
and  we  shall  see  that  they  may  originate  from  many  causes,  such  as  dis- 
ease of  the  muscles,  nerves,  bones,  and  joints,  or  from  cicatricial  shrink- 
age. As  regards  inflammatory  contractures,  it  may  be  briefly  noted  that 
every  inflani^ed  muscle  loses  its  elasticity  and  extensibility' to  a  greater 
or  less  extent,  and  that  the  patient  instinctively  avoids  the  pain  due 
to  the  stretching  of  the  muscle  by  shortening,  or,  in  other  words,  con- 
tracting it.  The  inflammatory  muscular  contracture  originates  in  this 
way,  and  may  become  very  severe.  In  this  class  of  inflammatory, 
])urelT  myogenic  contractures,  belong  also  the  so-called  isch^emic  mus- 
cular paralyses  and  muscular  contractures,  such  as  those  which  follow 
the  too  tight  application  of  dressings,  and  which  were  first  accurately 
described'  by  Tolkmann,  and  then  by  Leser.  The  isch?emic  contract- 
ures and  paralyses  are  produced  by  cutting  off  the  arterial  supply,  es- 
pecially of  the  hand  and  forearm,  for  too  long  a  time  by  tight  dress- 
ings, Esmarch's  constriction,  ligation  and  injuries  of  the  larger  vessels, 
as  well  as  by  the  prolonged  action  of  excessive  cold.  The  contractile 
muscular  substance  coagulates,  undergoes  waxy  degeneration,  and  is 


550    INJURIES   AND   SURGICAL   DISEASES  OF  THE   SOFT   PARTS. 

subsecjuently  absorl)etl  (Ileidell)erg,  Kraske).  There  is  regularly  found 
a  noticeable  diminution  or  absence  of  muscular  nuclei  (Molitor),  and 
the  nuclei  of  the  smallest  capillaries  also  share  in  these  changes.  In 
sucli  cases  the  muscle  is  no  longer  ea})able  of  regeneration  ;  it  dies.  It 
is  really  a  rigor  mortis  of  the  muscle,  thougli  the  nerves  retain  their 
power  of  conduction.  If  the  isclifemia  does  not  last  so  long  a  time. 
only  a  part  of  the  muscular  fibres  undergo  degeneration,  and  the  rest 
persist  and  retain  their  power  of  regeneration.  The  ischsemic  con- 
tracture is  marked  by  a  high  grade  of  resistance  to  extension  into  a 
straight  position.  The  prognosis  of  the  ischa^mic  paralysis  and  con- 
tracture depends  upon  the  number  of  muscular  fibres  which  have 
perished,  the  worst  cases  being  incurable,  and  even  the  milder  ones 
requiring  vigorous  treatment  by  massage,  electricity,  and  passive  mo- 
tion. An  attempt  should  always  be  made  to  stretch  the  shortened  and 
stiffened  muscles,  if  necessary,  under  chloroform  narcosis. 

Myositis  Serosa  and  Sero-fibrinosa. — The  slight  degrees  of  inflam- 
mation of  muscle — the  myositis  strosa  and  sero-jihrinosa — which  may 
follow  contusions,  for  example,  are  characterised  anatomically  by  a 
saturation  of  the  perimysium  with  serum  and  by  cellular  infiltration, 
particularly  between  the  muscle  fibres.  The  latter  remain  intact,  or, 
according  to  the  nature  of  the  excitant  of  the  inflammation,  they  un- 
dergo a  cloudy  swelling,  fatty  degeneration,  and  coagulation  necrosis. 
The  defect  in  the  contractile  muscular  fibres  is  more  or  less  restored  by 
proliferation  of  the  muscular  corpuscles  (see  page  -fOS,  Kegeneration 
of  Muscle).  If  a  severer  grade  of  inflammation,  such  2i?,  o.  purulent 
myositis,  occurs,  the  muscular  fibres  are  destroyed  ei}  masse  by  degen- 
erative processes;  they  break  down  and  undergo  suppuration  and 
putrefaction.  Myositis  purulenta  may  be  acute  or  chronic,  taking  the 
form  of  muscular  abscesses  or  of  a  diffuse  suppuration  or  putrefaction, 
as  described  in  the  chapter  on  Cellulitis.  The  suppurative  and  gan- 
grenous inflammations  of  muscle  are  always  due  to  bacterial  infection, 
and  are  observed  in  conjunction  with  infected,  septic  wounds  of  vari- 
ous kinds,  occurring  in  the  course  of  py?emia,  erysipelas,  typhoid, 
glanders,  endocarditis,  etc.  Multiple  abscesses  in  different  muscles 
often  occur  in  great  numbers.  The  muscular  abscess  occurring  in 
the  course  of  tuberculosis,  the  so-called  cold  abscess,  such  as  the  tuber- 
cular abscess  or  suppuration  of  the  psoas  muscle  following  tubercular 
disease  of  the  vertebrse.  runs  an  exceedingly  chronic  course  unless  it 
receives  energetic  surgical  treatment.  Diffuse  suppurative  and  gan- 
grenous changes  in  muscle  are  particularly  apt  to  make  their  appear- 
ance in  conjunction  with  a  compound  fracture  which  has  not  been 
treated  aseptically. 


98.] 


THE   DISEASES  OP  MUSCLES. 


551 


Wlierevcr  imiscular  tissue  has  been  destroyed  by  suppuration  or 
gangrene  there  will  remain,  after  healing  has  been  accomplished,  a 
permanent  defect  wliich  is  repaired  by  connective  tissue,  since,  as  we 
remarked  on  page  408,  contractile  muscular  substance  possesses  but 
slight  powers  of  repair.  Corresponding  to  the  size  of  the  defect,  the 
connective-tissue  adhesions  and  the  increasing  cicatricial  contraction, 
disturbances  in  the  functions  of  the  muscles  will  subsequently  develo}) 
in  the  form  of  contractures,  which  may  render  the  affected  extremity 
completely  useless. 

Myositis  Fibrosa. — Clironic  inflammations  of  nniscle  take  the  form 
of  a  inyuaitls  jibrom.  In  this  we  have  to  deal,  in  the  main,  with  a 
growth  of  firm  connective  tissue  between  the  muscular  fasciculi  and  a 
proportionate  atrophy  of  the  latter.  This  fibrous  myositis,  or  sclerosis  of 
a  muscle,  occurs  either  diffusely,  changing  the  entire  muscle  into  tough 
connective-tissue  masses,  or  it  is  confined  to  certain  spots.  In  this 
category  belongs  the  myositis  fibrosa  of  the  biceps  or  sterno-mastoid 
muscles,  for  example,  occurring  in  the  course  of  syphilis,  or  after 
paralyses,  or  primary  muscular  atrophies  due  to  different  causes. 

Myositis  Ossificans. — Special  interest  attaches  to  myositis  ossijicmis. 
The  development  of  bone  in  muscle  is  observed  under  various  patho- 


Fig.  329.— Ossified  M.  braehialis  iiUerniis  :  the 
tendon  is  not  ossified  (Blasius  and  Volk- 
raann). 


Fir. 


,  330. — Myositis  o.ssificans  multiplex 
progressiva  of  the  muscles  of  the  hack 
m  a  man  twenty-four  yeare  old  (Helf- 
reich). 


logical  conditions;  for  example,  in  conjunction  with  callus  formation 
after  a  fracture.     Bone  occasionally  forms  in  muscle  as  a  result  of 


552    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT   PARTS. 

some  frequently  repeated  traumatism,  such  as  the  kick  of  a  gun,  which 
may  give  rise  to  tlie  development  of  bone  in  the  biceps  and  pectoralis 
muscles  (the  so-called  exercise  bones).  Kiding  may  lead  to  bony  for- 
mation in  the  adductors  of  the  thigh  (riders'  bone).  In  rare  instances 
osteomata,  not  connected  with  any  bone,  have  been  observed,  for  which 
no  cause  could  be  discovered.  Fig.  329  represents  a  case  in  which  the 
brachialis  anticus  was  completely  changed  into  bone.  Diims  observed, 
in  connection  with  the  formation  of  bone  in  the  deltoid  muscle,  a  reflex 
neurosis,  consisting  of  tremor  and  pains  in  the  entire  arm  down  to 
the  finger  tips,  which  only  occurred  when  the  gun  pressed  upon  the 
exercise  bone  (osteoma;,  and  disappeared  completely  after  its  extirpa- 
tion. 

Myositis  Ossificans  Multiplex  Progressiva.^This  is  a  very  peculiar 
affection  which  generally  begins  during  childhood.  A  great  number 
of  muscles  gradually  change  into  bone,  causing  the  condition  of  the 
patient  to  become  extremely  deplorable.  After  the  reception  of  some 
slight  traumatism,  or  without  any  apparent  reason,  painful,  dougliy 
swellings  develop  in  the  muscles  and  intermuscular  connective  tissue, 
and  in  a  few  days  they  disappear.  The  muscle,  at  the  point  where  it 
has  been  attacked,  then  feels  hard,  and  true  bone  gradually  develops. 
Nodular,  branching  masses  of  bone  develop,  especially  in  the  muscles 
of  the  back  and  neck  (Fig.  330).  The  jaws  may  be  firmly  held  to- 
gether by  ossification  of  the  masseters,  and  the  movements  of  thje  ver- 
tebrae and  the  different  joints  may  become  lost  in  consequence  of  the 
ossification  of  the  muscles,  tendons,  and  ligaments.  These  pitiable  in- 
dividuals finally  die  in  misery  from  motor  disturbances,  or  from  inter- 
ference with  respiration  and  nutrition.  The  bone  always  develops  in 
the  connective  tissue  in  a  manner  analogous  to  the  periosteal  formation 
of  bone,  and  the  muscular  filtres  are  passive  throughout  the  entire 
process. 

The  nature  of  tliis  very  remarkalile  disease  is  still  but  little  under- 
stood. There  is  evidently  a  pronounced  tendency  to  the  formation  of 
bone  in  the  connective  tissue  of  the  muscles,  fascia,  tendons,  and  liga- 
ments, as  though  periosteum  had  strayed  into  these  tissues.  The 
affection  is,  in  all  probability,  a  congenital  anomaly  of  development, 
especially  as  in  some  cases  malformations  of  the  extremities  have  been 
present  at  the  same  time  (micro-dactylia,  congenital  anchylosis  in  the 
joints  of  the  big  toes  and  of  the  thumbs).  In  some  of  the  cases  the 
process  should  be  looked  upon  as  a  formation  of  multiple  exostoses, 
with  secondary  muscular  ossification.  At  all  events,  I  cannot  regard 
the  nature  of  the  disease  as  inflammatory,  but  rather  as  one  of  tumour 
formation. 


^!)8.J  THE   DISEASES  OF   MUSCLES.  553 

The  treatment  of  the  severe  cases  of  myositis  ossificans  oilers  no 
hope,  but  the  milder  cases  may  derive  some  benefit  from  iodide  of 
potassium  and  inunctions  of  ungt.  liydrarg.  cincr.  AVhenever  possible, 
operative  measures  slu)uld  be  undertaken— i.  e.,  the  ossified  muscle 
should  be  extirpated,  and,  if  it  be  connected  with  the  periosteum  and 
bone,  the  periosteum  and  cortical  layer  of  bone  should  also  be  re- 
moved. 

The  treatment  of  the  above-mentioned  acute  and  chronic  inflamma- 
tions of  muscle  is  conducted  upon  the  lines  whicli  have  been  laid  down 
for  the  treatment  of  inflammation  and  suppuration. 

Calcification  of  the  Muscles  has  no  clinical  importance.  It  occurs  in 
the  neighbourhood  of  inspissated  abscesses  and  in  indurated  inflam- 
matory swellings.  Extensive  calcification,  such  as  Meyer  observed  in 
the  muscles  of  the  leg,  is  exceedingly  rare. 

Muscular  Rheumatism.— Acute  and  chronic  muscular  rheumatism 
depend  upon  inflammatory  changes  which  are  quite  transitory  in 
their  nature.  There  are  usually  no  gross  anatomical  changes  in  a 
chronic  muscular  rheumatism  which  has  lasted  for  years  ;  but  the 
acute  form  is,  for  the  most  part,  a  serous  or  sero-fibrinous  myositis. 
We  still  know  but  very  little  about  the  nature  of  muscular  rheumatism. 
The  manifestations  of  acute  muscular  rheumatism  are  very  much  like 
those  exhibited  after  subjecting  the  nniscles  to  some  traumatism.  It 
occurs  especially  as  lumbago  and  as  rheumatism  of  the  sterno-mastoid 
muscle  (rheumatic  torticollis).  In  addition  to  the  rheumatic  forms  of 
lumbago  there  is  also  a  traumatic  form  which  follows,  for  example, 
forced  forward  flexion  of  the  back.  The  rheumatic  affection  of  the 
sterno-mastoid  is  usually  accompanied  l)y  a  marked  contraction  of  the 
muscle,  causing  the  head  to  be  inclined  towards  the  aftected  side  (rheu- 
matic caput  ohstiptim). 

Chronic  muscular  rheumatism  is  characterised  by  shooting,  tearing, 
o^enerally  vague  pains  in  the  substance  of  the  muscle,  which  are  usually 
excited  or  increased  by  bad  weather.  In  the  subsequent  course  of  a 
given  muscular  rheumatism  it  often  turns  out  that  some  constitutional 
disease  is  present,  such  as  syphilis,  tuberculosis,  carcinoma,  etc.  The 
best  treatment  for  the  true  acute  and  chronic  muscular  rheumatism 
consists,  according  to  my  experience,  in  the  use  of  massage,  in  the  dili- 
gent exercise  of  the  affected  muscles,  and  also  in  cold-water  cures  and 
the  use  of  warm  springs  (Teplitz,  Wiesbaden,  Eehme,  Gastein,  etc.). 
Electricity  is  also  serviceable;  but  massage,  skilfully  administered 
and  combined  with  muscular  exercise,  is  the  best  therapeutic  measure. 

Tuberculosis  of  Muscles. — Tuberculosis  of  the  muscles  is  most  com- 
monly secondary  to  tubercular  disease  of  the  surrounding  parts,  or  it 


554    INJURIES  AND   SURGICAL   DISEASES  OF   THE  SOFT  PARTS. 

follows  deposition  of  the  tubercle  bacilli  by  the  circulation,  such  as 
occurs  in  general  miliary  tuberculosis  (see  §  83,  Tuberculosis). 

Syphilis  of  Muscles. — Syphilis  may  become  localised  in  muscles, 
occurring  sometimes  in  a  diffuse  form,  as  myositis  fibrosa,  and  some- 
times circumscribed,  as  a  gumma  tumour,  especially  in  the  sterno- 
mastoid  muscle.  Braman  is  right  in  calling  attention  to  the  fact  that 
many  of  the  so-called  rheumatic  indurations  of  muscle  are  due  to 
syphilis. 

Muscular  Atrophy. — Atrophy  of  the  muscles  is  observed  in  various 
pathological  conditions.  Atrophy  and  degeneration  may  follow  inac- 
tivity of  tlie  muscles  (atrophy  of  disuse),  such  as,  for  example,  occurs 
temporarily  after  the  application  of  innnobilising  dressings  for  joint 
disease ;  or  it  may  be  due  to  disease  of  the  central  or  peripheral  nerv- 
ous system  (neuropathic  atrophies),  or  to  the  above-mentioned  inliam- 
niatory  processes,  traumatisms,  etc.  The  muscular  atrophy  accompany- 
ing joint  affections  is  sometimes  not  the  result  of  disuse,  but  is  caused 
by  the  local  disease  near  by — that  is,  by  an  involvement  of  the  muscles 
in  the  diseased  process  going  on  in  the  joint,  as  is  the  case  particularly 
in  acute  articular  rheumatism  (Striimpell).  According  to  Paget,  Hoffa, 
and  others,  the  muscular  atrophy  accompanying  joint  disease  is  essen- 
tially reflex  in  its  nature — i.  e.,  the  terminations  of  the  nerves  in  the 
joints  are  irritated  by  the  inflannnation  going  on  there.  This  irrita- 
tion is  carried  centripetally  to  the  ganglion  cells  in  the  anterior  horns 
of  the  grey  matter  in  the  spinal  cord — i.  e.,  to  the  spinal  centres  of 
the  nerves  governing  the  nutrition  of  the  atrophying  muscles — and 
excites  in  them  certain  changes  which  produce  the  muscular  atrophy. 
The  reflex  atrophy  does  not  take  place  in  dogs,  for  example,  when  the 
knee-joint  is  inflatned,  if  the  posterior  roots  of  the  third,  fourth,  and 
fifth  lumbar  and  first  sacral  nerves  have  been  divided  (Iloffa,  and 
others). 

Anatomically,  we  distinguish  the  following  forms  of  muscular 
atrophy  : 

1,  Simple  atrophy  of  the  muscular  fibres;  2,  atrophy,  with  an  inter- 
stitial growth  of  fat  cells  (lipomatosis  of  the  muscles) ;  and,  3,  degener- 
ative atro])hy. 

In  simple  muscular  atrophy  following  local  or  constitutional  dis- 
turbances of  nutrition,  the  muscular  fibres  decrease  in  size  and  num- 
ber, and  no  other  anatomical  changes  can  be  found.  Atrophy  of  the 
muscular  fibres,  with  a  growth  of  adipose  and  connective  tissue  between 
the  muscular  fibres,  is  frequently  observed.  Generally  the  growth  of 
tlie  fat  and  connective-tissue  cells  is  secondary  to  primary  atrophy  and 
degeneration  of  the  nmscles.     Occasionally  the  development  of  fatty 


g!)8.J  THE   DISEASES  OP   MUSCLES.  555 

tissue  in  the  muscle  is  so  extensive  tliat  the  latter  increases  in  size. 
This  is  tlie  case  in  atropliia  inuseuh)rnni  liponiatosa. 

Pseudo-Hypertrophica  or  Dystrophia  Muscularis  Progressiva  (Erb). — 
This  disease  occurs  ahnost  exclusively  in  children,  ])articularly  boys, 
and  consists  in  a  gi-adually  developing  einiple  atrophy  of  the  muscles, 
with  a  secondary  interstitial  growth  of  fat  cells,  which  may  become 
so  pronounced  that  numy.  muscles — anu)ng  others  those  in  the  calf 
of  the  leg — become  considerably  increased  in  size.  In  addition  to 
these  abnormally  hypertrophied  muscles  there  are  others  which  are 
greatly  emaciated.  The  atro})hy  spreads,  and  involves  the  gi-eater  j)ai't 
of  the  muscular  system;  the  paralysis  of  the  muscles  steadily  increases, 
and  the  patients  become  constantly  more  helpless.  Death  usually 
occurs  within  live  to  ten  to  fifteen  years  from  marasmus  or  from 
])aralysis  of  the  muscles  of  respiration.  The  pseudo-hypertrophy  is  a 
primary  disease  of  the  muscles,  and  is  probably  due  to  a  congenital 
change  in  the  muscular  tissue,  which,  at  the  period  when  development 
takes  place,  leads  to  a  growth  of  fat  in  the  perimysium  internum  and 
to  atrophy  of  the  muscular  fibres. 

Fatty  Degeneration. — The  fatty  degeneration  of  the  muscular  libi-es 
belongs  to  the  degenerative  atrophies  of  muscle.  In  this  the  primitive 
muscular  fasciculi  change  into  fat  as  a  resnlt  of  inflammatory  processes, 
or  inactivity  due  to  paralysis,  or  of  trophic  disturbances  due  to  a  degen- 
eration of  the  anterior  roots  of  the  spinal  nerves;  or  it  may  occur  in 
connection  with  an  anchylosis  or  one  of  the  acute  infectious  diseases 
(typhoid  fever,  diphtheria),  or  may  follow  phosphorus  poisoning,  etc. 
The  so-called  progressive  muscular  atrophy  belongs  to  this  group.  The 
form  of  progressive  muscular  atrophy  described  by  Duchenne  and  Aran 
is  produced  by  spinal  disturbances,  while  other  forms  are  dependent 
upon  multiple  disease  of  nerves,  or  have  the  nature  of  primary  muscu- 
lar affections.  To  this  latter  class  of  cases  belongs  juvenile  muscular 
atrophy  (Erb),  which  runs  its  course  sometimes  with  and  sometimes 
without  lipomatosis.  The  atrophy  of  the  muscles  is,  for  the  most 
part,  primary,  and  as  it  increases  paralysis  gradually  develops.  The 
disease  begins  in  a  particular  group  of  muscles,  often,  for  example, 
in  the  hand  or  the  ball  of  the  thumb.  The  atrophy  then  spreads  in- 
termittently, and  in  the  severest  cases  gradually  attacks  the  majority  of 
the  muscles.  Progressive  muscular  atrophy  belongs  to  the  domain 
of  nervous  diseases,  and  consetjuently  we  cannot  take  it  up  more  fully 
here. 

"Waxy  Degeneration  occurs  especially  in  typhoid  and  puerperal 
fevers  as  a  result  of  contusions,  in  tetanus,  and  after  the  muscles  have 
become  thoroughly  tired   out  by  electrical  stimulation  (Roth).     We 


556    INJURIES   AND   SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

have  to  deal  in  this  condition  with  a  death  and  a  coagulation  of  the 
contractile  muscular  substance  into  a  translucent  hyaline  mass. 

Amyloid  Degeneration  of  the  Muscles. — xVm^loid  degeneration,  which 
may  involve  the  muscles  of  the  tongue  and  larynx  as  a  result  of  inflam- 
matory processes,  is  a  very  rare  disease  of  muscle.  According  to  Zieg- 
ler,  amyloid  degeneration  affects  the  perimysium  internum  and  sarco- 
lernma,  causing  them  to  become  thickened  and  present  a  homogeneous 
appearance,  while  the  contractile  substance  disappears. 

Hypertrophy. — Jlu-sciilar  Jtypertropliy  has  no  practical  intei'est ;  it 
is  partly  acquired  and  partly  congenital. 

Muscular  Defects. — Congenital  muscular  defects,  which  may  occur  in 
tlie  pectoralis  majur  and  minor  and  in  other  muscles,  should  also  be 
mentioned. 

Turaours  of  muscles  are  discussed  under  the  subject  of  tumours.  Of 
animal  parasites  which  occur  in  muscles  there  are  the  trichina,  the  cys- 
ticercus  cellulosge,  and  the  echinococcus  (see  Special  Surgery).  Marguet 
states  that  the  echinococcus  is  found  most  frequently  in  the  adductors 
of  the  thigh,  in  the  glutaei,  the  quadratus  femoris,  biceps  of  the  arm, 
the  pectorales,  the  trapezius,  deltoid,  and  muscles  of  the  back  and  ab- 
domen. They  form  fluctuating  tumours  which  should  be  removed  by 
extirpation  or  by  incision,  followed  by  scraping  them  out.  Actinomy- 
cosis of  muscles  is  described  in  ^  86. 

Inflammations  of  the  Tendons  and  Tendon  Sheaths  may  occur,  in  the 
flrst  place,  as  a  tenosynovitis  acuta  sicca  (tenalgia  crepitans),  a  form 
which  corresponds  to  dry  pleurisy  (pleuritis  sicca).  This  is  character- 
ised by  a  deposition  of  fibrin  upon  the  inner  surface  of  the  tendon 
sheath  and  upon  tlie  surface  of  the  tendon.  As  a  result  of  this  rough- 
ening, when  the  tendon  is  moved  a  soft  crepitation  or  a  grazing  or 
creaking  sound  is  communicated  to  the  hand  held  over  the  inflamed 
region.  This  form  of  tenosynovitis  affects  most  commonly  the  exten- 
sor tendons  of  the  forearm  in  individuals  who  work  at  heavy  manual 
labour ;  it  may  also  occur  in  the  tendons  of  the  leg  (the  tibiales  and 
Achilles  tendons)  after  a  long  march,  for  example. 

The  treatment  of  tenalgia  crepitans  consists  in  painting  the  parts 
with  tincture  of  iodine^'  in  immobilising  them  with  proper  dressings 
(splints,  etc.)  and  applying  moderate  pressure  with  cotton,  and  later 
employing  massage  and  passive  motion.  I  use  massage  as  soon  as  pos- 
sible.    Recovery  usually  takes  place  in  one  to  two  to  three  weeks. 

Tenosynovitis  Acuta  Purulenta. — Suppurative  inflammation  of  the 
tendons  and  tendon  sheaths  (tenosynovitis  acuta  purulenta)  is  most 
commonly  the  result  of  some  injury  which  lias  not  been  treated  anti- 
septically,  and  of  a  suppurative  process  in  the  neighbourhood.    Suppu- 


§1)8.]  THE    DISEASES  OF   MUSCLES.  557 

rative  inflammation  of  the  tendons  and  tendon  slieatlis  lias  been  de- 
scribed under  the  subject  of  CeHuUtis,  in  §  70,  and  consequently  will  he 
oidy  briefly  mentioned  here.  In  the  Angers,  especially,  the  so-called 
paronychia  or  whitlow  easily  spreads  to  the  tendon  sheaths  (panaritium 
tendinosum).  Suppurative  tenosynovitis  is  characterised  by  a  collec- 
tion of  pus  between  the  tendon  and  its  sheath,  and  by  a  cellular  infll- 
trationof  the  intrafascieular  connective  tissue.  The  milder  cases,  which 
are  treated  by  incision  and  antiseptic  dressings,  terminate  in  a  re,sti- 
tutlo  ad  int<'(j)'Hnh ;  in  others,  an  adhesion  of  the  tendon  to  the  tendon 
sheath  or  a  necrosis  of  the  tendon  take  place. 

The  treatment  of  suppurative  tenosynovitis  consists  in  making  an 
incision  at  the  earliest  possible  moment,  followed  by  drainage  and  anti- 
septic dressings  (bichloride  of  mercury,  iodoform).  It  is  a  very  impor- 
tant matter  to  place  the  diseased  limb  in  a  suitably  elevated  position. 
If  the  hand,  for  example,  is  involved,  it  should  be  suspended  vertically 
by  means  of  suspension  splints  (see  Fig.  1Y7).  If  the  suppuration  of 
the  tendon  sheaths  is  extensive,  the  same  treatment  should  be  employed 
as  was  described  for  cellulitis  in  §  TO.  The  cataplasms  which  used  to 
be  employed  have  been  given  up  entirely,  and  the  ice  treatment  is  also 
not  very  effective.  Whenever  it  is  possible,  suppuration  should  always 
be  anticipated,  and  its  extension  should  be  prevented.  If  necrosis  of 
the  tendon  occurs,  care  should  be  taken  to  keep  the  affected  portion  of 
the  limb  in  the  position  in  which  it  will  be  the  most  useful  afterwards. 
The  treatment  of  defects  in  tendons  is  discussed  on  page  407. 

Tuberculosis  of  the  Tendon  Sheaths. — Tubercular  tenosyno\itis  occurs 
both  as  a  primary  disease  and  secondary  to  tuberculosis  in  the  neigh- 
bourhood. Primary  tuberculosis  of  the  tendon  sheaths  is  not  so  rare 
as  used  to  be  believed  ;  it  develops  occasionally  from  some  traumatism 
(contusion,  sprain).  Tubercular  tenosynovitis  is  characterised  by  the 
formation  of  miliary  tubercles,  greyish-red,  gelatinous  granulation  tis- 
sue, and  in  the  later  stages  by  the  formation  of  caseous  or  suppurat- 
ing masses  which  are  distributed  along  the  tendon.  In  the  benign 
cases  of  tuberculosis  of  the  tendon  sheaths,  Goldmann  states  that  the 
process  is  a  fibrinoid  degeneration,  and  that  cheesy  degeneration  does 
not  occur.  The  fil)rinoid  degeneration  often  leads  to  the  formation  of 
rice  bodies — that  is,  the  degenerated  fibi-ous  and  villous  growths  break 
loose  and  become  free  corpuscles  (corpuscula  oryzoidea),  which  are 
like  grains  of  rice  ;  in  this  way  the  so-called  i-ice-body  hygi-oma  dev^el- 
ops  (see  page  559). 

The  treatment  of  tubercular  tenosynovitis  consists  in  carefully  re- 
moving the  tubercular  deposit  with  the  scissors,  forceps,  and  sharp 
spoon.     I  have  obtained  excellent  results,  and  even  entire  cures,  in 


558    INJURIES   AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

primary  tuberculosis  of  tendon  sheaths.  Care  must  always  be  taken 
that  every  bit  of  the  diseased  tissue  is  removed.  Iodoform  injections 
which  are  well  worth  recommending  are  discussed  on  page  420.  Losses 
of  substance  in  tendons  can  be  remedied  as  descril)ed  on  page  4G7. 

Hydrops  Tenovaginalis  {Hygroma  of  the  Tendon  Sheaths). — By  hy- 
groma or  hydrops  tenovaginalis  is  understood  a  cystic  formation  which 
occurs  especially  in  the  tendon  sheaths  of  the  hand,  particularly  in  the 
palm,  where  it  affects  the  flexor  tendons  beneath  the  anterior  annular 
ligament,  also  in  the  fingers  and  on  the  dorsum  of  the  hand.  It  con- 
sists essentially  of  an  abnormal  increase  in  the  secretion  of  the  tendon 
sheath.  Some  hygromata  are,  as  we  have  said,  tubercular  in  their 
origin.  To  avoid  repetition,  we  shall  discuss  In'groma  of  the  tendon 
sheath,  together  with  hygroma  of  bursse,  in  §  99. 

Tumours  of  Tendon  Sheaths. — We  shall  return  to  tumours  of  the  ten- 
don sheaths  under  the  subject  of  tumours.  Fibromata,  fibi'osarconiata, 
sarcomata  and  lipomata  are  liable  to  occur  in  this  situation.  The  latter 
kind  of  tumour  occasionally  forms  diffuse  growths  (lipoma  arborescens) 
which  are  sometimes  symmetrical. 

Myotomy  and  Tenotomy. — Brief  mention  should  here  be  made  of  the 
subcutaneous  division  of  muscles  and  tendons — subcutaneous  myotomy 
and  tenotomy — an  operation  which  is  often  practised  for  conti'actures. 
The  operation  is  performed  in  the  following  manner :  The  tenotome, 
a  pointed,  slightly  curved  knife  (see  Fig.  45,  page  00),  is  introduced 
with  antiseptic  precautions,  and  the  muscle  or  tendon — it  may  be  the 
tendo-Achillis  or  contracted  fascia  —  is  cut  through  subcutaneously. 
The  small  punctured  w^ound  is  covered  with  an  antiseptic  dressing 
which  exerts  pressure.  The  defect  which  forms  between  the  retracted 
ends  of  the  tendon  is  then  filled  in  by  newly  developed  connective  tis- 
sue. The  missing  portion  of  tendon  becomes  entirely  regenerated,  and 
the  muscle  suffers  no  loss  of  function.  The  intervening  portion  of  ten- 
don is  developed  from  the  cellular  sheath,  that  wide-meshed  connective 
tissue  which  partly  envelops  the  tendon  and  is  partly  inserted  upon  it 
by  means  of  bands  (vincula  tendinum).  The  technirpie  and  indications 
for  myotomy  and  tenotomy  in  particular  portions  of  the  body  is  dis- 
cussed in  the  Special  Surgery. 

§  99.  The  Diseases  of  the  Bursae. — The  bursse  mucosae  are  more  or 
less  sharply  defined  connective-tissue  sacks  having  a  smooth  inner 
surface  which  is  covered  with  endothelium,  and,  like  the  joints,  secretes 
synovia. 

Origin  and  Occurrence  of  Bursae. — Bursae,  as  a  rule,  develop  in  places 
where  the  skin,  fascia,  muscles,  etc.,  are  subjected  to  continual  pressure  and 
friction,  particularly  over  bony  prominences.     This  explains  why  the  num- 


S99.]  THE   DISEASES   OF  THE   BURS^.  559 

ber  of  bursnc  is  not  constant,  and  why  bursa?  form  in  portions  of  the  body 
otlier  tlian  where  they  normally  occur  (so-ealled  accidental  or  supernumerary 
bui-sai).  One  may  thus  develop  upon  the  first  metatarsal  bone  in  hallux  val- 
gus, over  the  spinous  processes  in  ky])hosis  of  the  vertebra,%  upon  the  sternum 
of  shoemakers,  etc.  Young  children  lack  a  large  number  of  bursae  which 
subsequently  develop  as  the  parts  become  subjected  to  increased  use.  Bursae 
originate  from  the  soft  connective  tissue  which  lies  between  two  layers  of 
tissue,  and  which  becomes  more  and  more  wide-meshed.  The  space  in  the 
tissues  is  at  the  outset  irregular  and  contains  atrophied  connective-tissue 
fibres,  but  it  develops  by  degrees  into  a  complete  sack  with  smooth  walls 
and  endothelium  like  any  other  connective-tissue  space.  The  number  of  the 
more  or  less  constant  bursae  is  very  great.  Gruber  found  eighteen  in  the 
parts  around  the  knee  joint  and  eleven  bureae  musculares  at  the  elbow  joint, 
in  addition  to  the  bursa  anconea  epitrochlearis  and  epicondylica.  Velpeau 
found  fourteen  bursae  on  the  dorsum  of  the  hand,  etc. 

Acute  Inflammation  of  a  Bursa. — The  acute  inflammation  of  a  bursa 
(acute  liygroma,  bursitis  acuta)  is  either  serous,  sero-fibrinous,  or  puru- 
lent. All  cases  of  acute  bursitis  give  rise,  in  consequence  of  the  in- 
creased secretion,  to  a  more  or  less  prominent  fluctuating  tumour.  The 
purulent  inflammation  occasionally  takes  on  a  phlegmonous  character, 
causing  the  pus  to  burrow  into  the  neighbouring  cellular  tissue  or  into 
joints,  etc.  The  bursa  most  commonly  inflamed  is  the  bursa  prsepatel- 
laris  (see  Special  Surgery). 

Chronic  Inflammation  of  Bursae  (Hygroma). — The  most  common  form 
of  the  chronic  inflammation  of  bursse  is  the  hydi-ops  or  hygroma.  In 
the  majority  of  instances  it  occurs  as  a  painless  fluctuating  tumour,  with- 
out change  in  the  cutaneous  covering.  Its  contents  consist  of  a  thick, 
mucoid  liquid.  The  shape  of  the  tumour  corresponds  to  the  degree  of 
extension  of  the  bursa.  The  hygroma  prfepatellare  is  the  most  com- 
mon of  all  hygromata  of  bursae  (see  Special  Surgery).  Should  a  com- 
munication exist  between  the  hygroma  and  a  joint,  a  corresponding 
serous  effusion  will  be  found  in  the  latter.  Hygromata  sometimes 
develop  in  connective  tissue  from  fibrinous  exudation  without  the  pre- 
vious formation  of  a  bursa. 

In  other  cases  of  hygroma  the  walls  become  thickened  to  a  greater 
or  less  extent  (fibrous  degeneration),  particularly  if  the  disease  has  ex- 
isted a  long  time,  or  a  villous  growth  takes  place  in  the  bursa  and  the 
villi  may  break  loose  and  form  rice  bodies  (corpuscula  oryzoidea).  Oc- 
casionallj'  there  will  be  so  many  free  bodies  in  the  hygroma  that  tlie 
latter  feels  like  a  bag  filled  M'ith  shot  (ganglion  crepitans,  hygro"ia 
proliferum).  The  free  bodies,  according  to  Meckel  and  Yolkmann, 
originate  partly  from  the  breaking  loose  of  the  villous,  fibrillar  growths 
which  become  enlarged  by  infiltration  and  deposits  of  the  albuminous 
and  fibrinous  matter  contained  in  the  synovia,  and  partly  from  the 


560    INJURIES  AND  SURGICAL   DISEASES   OF   THE   SOFT    PARTS. 

precipitation  or  coagulation  of  the  thickened  contents  of  the  hygroma. 
Schuchardt  states  that  the  rice  bodies  are  formed  mainly  by  the  break- 
ing loose  of  the  degenerated  portions  of  tissue  from  the  walls  of  the 
bursa,  tenden,  or  tendon  sheath  after  they  have  undergone  coagulation 
necrosis  (AVeigert)  or  a  fibrinous  degeneration  (Neumann).  Free  bodies 
may  also  be  formed  by  growths  of  cartilage  which  break  loose  from  the 
hygroma.  The  shape  of  the  body  is  round,  elongated,  facetted,  or  like 
a  pear,  cucumber,  or  melon.  Their  number  varies  greatly,  often  reach- 
mor  manv  hundreds. 

The  hvgroma  of  the  tendon  sheaths  mentioned  on  page  558  pre- 
sents practically  the  same  manifestations  as  that  of  the  burste. 

A  hva'i'oma  originates  almost  always  from  mechanical  causes,  espe- 
ciallv  from  prolonged  mechanical  irritation,  from  contusions,  sprains, 
etc.  Volkmann  believes  that  the  rare  cases  of  multiple  hygromata  are 
occasionally  due  to  rheumatic  causes.  Syphilis  not  infrequently  gives 
rise  to  hygromata,  particularly  of  the  tendon  sheaths,  in  addition  to 
corresponding  serous  effusions  into  the  joints.  As  we  remarked  on 
page  557,  these  rice-body  hygromata  are  sometimes  tu])ercular  in  their 
nature,  running  a  comparatively  benign  course,  and  exhibiting  a  fibri- 
noid degeneration  of  the  tubercular  tissue,  but  not  a  cheesy  degenera- 
tion (Goldmann). 

Part  of  the  proliferating  hygromata  must  be  looked  upon  as  tu- 
mours, some  of  them  being  benign,  endothelial  growths  (Morisani),  and 
others  malignant,  sarcomatous  tumours  (Mikulicz). 

The  best  treatment  for  hygromata  consists  in  puncture  followed  l)y 
antiseptic  irrigation  with  a  l-to-1,000  solution  of  bichloride  of  mer- 
curv  or  a  three-per-cent.  solution  of  carbolic  acid ;  or,  better  still,  an 
incision  should  be  made  and  the  hygroma  extirpated  with  antiseptic 
precautions  as  completely  as  possible.  The  procedures  which  were 
practised  in  the  days  before  antisepsis  (application  of  the  tincture  of 
iodine,  pressure,  etc. )  are  uncertain  (see  Special  Surgery). 

The  treatment  of  acute  inflammation  of  bursas  is  conducted  accord- 
ing to  general  rules.  Painting  the  part  with  iodine,  pressure,  and 
massage  will  often  suffice  for  the  milder  serous  effusions.  If  there  is 
a  violent  inflammation  or  suppuration,  aseptic  incision  is  the  only 
proper  procedure.  It  will  be  sufficient  to  puncture  large,  purely 
serous  effusions,  with  or  without  the  addition  of  antiseptic  irrigation 
with  a  1-to  1,000  solution  of  bichloride  or  a  three-per-cent.  solution  of 
syn  uolic. 

Haematomata  of  the  Bursae.— The  effusion  into  the  bursa  is  bloody, 
when,  as  a  result  of  some  injury,  there  has  occurred  an  extravasation 
of  blood  into  the  bursa,  or  when  traumatic  or  inflammatory  haemor- 


§100.]  GANGRENE  (NP^CROSIS)   OF  THE  SOFT   PARTS.  561 

rhages  liave  taken  place  from  the  wall  of  the  liygroma.  The  treat- 
ment of  these  hieinatomata  of  bursas  is  essentially  the  same  as  that  for 
pure  hygromata. 

Ganglion. — The  so-called  ganglion  generally  takes  the  form  of  a 
round,  elastic  tumour,  lying  beneath  the  skin  and  occurring  in  the 
neighbourhood  of  joints,  particularly  those  of  the  hand  and  foot.  Many 
authorities  have  classed  it  with  the  hygromata  of  bursse  and  tendon 
sheaths,  but  Yolkmann  is  right  in  distinguishing  the  ganglion  from 
these.  lie  states  that  the  ganglia  have  a  genetic  connection  with  the 
joint  cavities,  less  often  with  the  tendon  sheaths,  and  are  to  be  regarded 
as  new  growths  in  a  limited  sense  of  the  word.  The  ganglion  origi- 
nates from  a  pouch-like  appendage  of  the  joint  or  diverticulum  of  the 
synovial  membrane.  The  diverticulum  becomes  filled  with  thickened 
synovia,  and  may  be  completely  cut  o£E  from  the  joint  by  obliteration 
of  its  pedicle ;  it  practically  becomes  an  independent  cystic  tumour. 
Ganglia  are  to  be  regarded  essentially  as  synovial  hernise.  Less  fre- 
quently they  originate  from  a  kind  of  cystic  degeneration  of  the  cap- 
sule, from  abnormity  in  the  secretion  of  the  synovia.  There  are,  it  is 
true,  intermediate  forms  between  ganglia  and  hygromata. 

The  treatment  of  ganglia  consists  in  bursting  them  subcutaneously 
by  pressure  with  the  finger,  or  by  the  blow  of  a  wooden  hammer,  or 
by  means  of  a  seal  covered  with  a  piece  of  linen  and  placed  upon  the 
tumour,  or  in  puncturing  or  incising  the  tumour  subcutaneously  with  a 
tenotome  and  then  applying  a  dressing  which  exerts  pressure.  Recur- 
rences are  very  common  after  these  methods  of  treatment.  The  surest 
and  safest  procedure  is  free  aseptic  incision,  followed  by  as  complete  an 
extirpation  of  the  ganglion  as  possible.  This  operative  treatment  is 
entirely  devoid  of  danger  if  the  rules  of  antisepsis  are  carefully  ob- 
served. (See  also  Special  Surgery  for  the  treatment  of  ganglion  at  the 
wrist.) 

'  §  100.  Gangrene  (Necrosis)  of  the  Soft  Parts. — When  treating  of  the 
subjects  of  inflammation  and  injuries,  we  showed  that  they  often  caused 
death  of  tissue,  mortification,  necrosis,  or  gangrene.  It  may  be  well  to 
give  at  this  point  a  concise  description  of  gangrene  of  the  soft  parts 
following  inflammation  and  injuries. 

Gangrene  is  to  be  regarded  as  a  disturbance  of  nutrition  arising 
from  local  vascular  changes,  diseases  of  the  nerves,  constitutional  dys- 
crasiae  (syphilis,  alcoholism,  diabetes,  etc.),  from  injuries  to  vessels  or 
nerves,  burns,  freezing,  in  the  course  0;^^  D-pupral  (bacterial)  infectious 
diseases  (pysemia,  septicaemia,  typhoid  tcTAV^-.  'rom  severe  local 

iiiflaramations,  such  as  cellulitis,  etc. 

Causes  of  Gangrene. — The  causes  of  tissue  death  are  as  follows :  1. 
36 


562    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT  I'ARTS, 

Interruption  of  the  afferent  flow  of  arterial  blood  without  the  develop- 
ment of  a  collateral  circulation,  such  as  may  occur  in  the  case  of  throm- 
bosis and  embolism,  or  after  ligation,  or  in  consequence  of  the  pressure 
of  a  tumour  or  inflammatory  exudate.  2.  Interruption  of  the  efferent 
flow  of  venous  blood.  3.  Interruption  or  stasis  of  the  circulation  in 
tlie  capillaries,  as  a  result  of  pressure,  coagulation  of  the  contents,  or 
disease  of  the  capillary  walls.  4.  Death  of  the  tissue-cells  without  any 
disturbance  of  circulation,  due  to  poisons,  such  as  a  snake  bite,  or 
to  micro-organisms  and  the  products  of  their  metabolism,  such  as  are 
found  in  infectious  diseases  of  wounds — for  example,  erysipelas,  cellu- 
litis, septicaemia,  etc.  The  various  causes  of  gangrene  are  frequently 
more  or  less  combined — for  example,  abnormally  high  or  low  tempera- 
tures cause  both  the  cells  and  the  vessels  to  lose  their  integrity  in  con- 
sequence of  the  coagulation  of  the  albumen.  The  different  tissues  pos- 
sess different  powers  of  resistance  against  the  above-mentioned  causes 
of  gangrene.  Cohnheim  states  that  a  loop  of  intestine,  for  example, 
will  die  if  exposed  for  a  couple  of  hours  to  a  temperature  of  8°  to  10° 
C.  (45°  to  50°  F.),  while  muscles  or  tendons  will  be  but  little  or  not 
at  all  affected  from  a  similar  exposure  to  the  same  influences.  The 
brain,  kidneys,  and  intestine  undergo  necrosis  within  one  or  two  hours 
after  interruption  of  the  afferent  flow  of  blood,  while  the  skin  and 
muscles  can  do  without  circulation  for  ten  or  twelve  hours.  The  tis- 
sues present  these  same  differences  when  subjected  to  traumatisms. 
The  brain  is  very  susceptible  to  traumatic  influences,  and  likewise 
to  loss  of  water,  while  the  skin,  connective  tissue  and  bones  are  much 
less  so. 

Local  and  general  anaemia,  venous  stasis,  disturbances  of  circulation 
from  diseases  of  the  vessels,  heart,  or  lungs,  or  disturbance  of  circula- 
tion due  to  inflammation — in  short,  faulty  circulation  from  any  cause — 
increases  the  disposition  to  gangrene  from  the  effects  of  mechanical, 
chemical,  or  thermal  influences.  Under  these  conditions,  comparatively 
slight  causes  may  suflice  to  bring  about  death  of  tissue. 

Senile  Gangrene. — Gangrajna  senilis,  for  example,  belongs  to  this 
class  of  cases ;  it  is  a  mortification  occurring  in  old  age  and  affecting 
the  toes  especially.  There  is  usually  an  accompanying  advanced 
arterio-sclerosis  with  chronic  disturbances  of  the  circulation,  and,  fol- 
lowing some  mild  inflammation  or  slight  traumatism,  complete  stasis 
takes  place  from  coagulation  of  the  blood  in  the  capillaries. 

Decubitus. — The  bedsore,  or  decubitus,  originates  from  some  slight 
injury,  particularly  in  patients  who  are  paralysed  ;  also  in  the  course  of 
severe  febrile  constitutional  diseases,  and  in  individuals  with  cardiac 
and  pulmonary  diseases  which  give  rise  to  stases.     Those  regions  are 


§100.]  GANGRENE  (NECROSIS)  OF  THE  SOFT   PARTS.  563 

particularly  endangered  where  the  skin  is  directly  superimj)osed  upon 
the  bone,  as  in  the  region  of  the  sacrum,  the  trochanters,  scapula,  ole- 
cranon, and  heel.  Portions  of  the  body  where  skin  presses  against 
skin,  as  in  the  scrotum  or  labia,  have  but  little  power  of  resistance  in 
individuals  with  circulatory  disturbances. 

In  still  other  instances  a  weak  constitution — in  other  words,  a  condi- 
tion in  which  the  cells  possess  slight  powers  of  resistance — favors  the 
occurrence  of  gangrene.  This  is  seen  in  old  people  with  advanced 
arterio-sclerosis  and  in  those  who  are  poorly  nourished. 

Noma.— This  is  the  reason  why  the  gangrene  which  spreads  so  rap- 
idly on  the  face,  the  so-called  cancrum  oris,  or  noma,  is  particularly 
likely  to  develop  in  individuals  who  are  very  much  reduced  and  in 
children  (see  Special  Surgery). 

Ergotine  Gangrene. — Poorly  nourished  individuals  are  the  ones  most 
commonly  affected  by  the  gangrene  occurring  in  chronic  ergotism, 
which  was  not  uncommon  in  the  middle  ages.  The  disease  results 
from  the  ingestion  of  bread  containing  the  ergot  of  rye.  Ergotism  is 
characterised  by  disorders  of  digestion,  by  general  weakness,  formica- 
tion, numbness  and  pains  in  the  extremities,  etc.  Then  a  rapidly 
spreading  gangrene  makes  its  appearance  involving  particularly  the 
toes,  and  whole  portions  of  the  extremities,  the  ears,  or  nose,  may  perish. 
The  main  cause  of  this  disease  is  probably  the  contractions  excited  in 
the  small  arteries  by  the  ergotine.  This  produces  anaemia  with  subse- 
quent gangrene,  especially  if  the  individual  is  badly  nourished  and 
marasmic.  According  to  Zweifel,  ergotine  gangrene  is  mainly  to  be 
ascribed  to  the  anaesthesia  caused  by  the  ergotine,  in  consequence  of 
which  injui'ious  influences  of  all  kinds,  such  as  traumatisms,  are  not 
perceived,  and  hence  the  individuals  affected  by  the  disease  are  unable 
to  protect  themselves.  ^ 

Gangrene  accompanying  an  Abnormal  Composition  of  the  Blood. — 
Mention  should  be  made  of  the  gangrene  occurring  when  the  composi- 
tion of  the  blood  becomes  altered,  as  in  ansemia,  hydrsemia,  and  diabetes 
mellitus.  In  the  latter  disease  gangrenous  inflammations,  particularly 
of  the  cellular  tissue,  are  apt  to  arise  after  the  reception  of  slight  inju. 
ries.  As  a  result  of  the  abnormal  composition  of  the  blood,  the  w^alls 
of  the  vessels  and  the  cells,  according  to  Cohnheim,  have  so  little  power 
of  resistance  that,  when  subjected  to  any  slight  traumatism  or  infection, 
disturbances  of  circulation  with  stasis  and  gangrene  readily  develop. 
But  the  diabetic  gangrene  in  the  vast  majority  of  instances  is  caused 
by  arterio-sclerosis  of  the  vessels,  as  in  senile  gangrene  (Heidenhain). 

Nervous  Gangrene. — Xervous  disturbances  may  also  favour  the  devel- 
opment of  gangrene.     This  is  the  exjDlanation  of  the  gangrene  accom- 


564    INJURIES  AND  SURGICAL   DISEASES   OF  THE  SOFT  PARTS. 

panying  leprosy  (§  85),  and  also  that  affecting  paralysed  portions  of  the 
body.  Either  the  trophic  nerves  lose  their  integrity ,_  or  the  necrosis  of 
tissue  and  ulceration  take  place  because  the  patients  do  not  feel  the 
irritations  of  the  skin,  and  thus,  as  in  ergotism,  cannot  avoid  the  in- 
jurious effects  of  such  irritation. 

The  so-called  malum  perforans  pedis,  a  punched-out,  progressive 
ulceration  of  the  sole  of  the  foot,  and  the  symmetrical  gangrenes,  are 
likewise  due  to  nervous  causes. 

Symmetrical  Gangrene. — According  to  Raynaud  and  Weiss,  sym- 
metrical gangrene  usually  appears  in  paroxysms,  affecting  the  fingers, 
toes,  and  less  often  other  portions  of  the  body.  This  rare  disease 
begins  with  para^sthesia  and  neuralgic  pains ;  then  cyanosis  or  anaemia 
develops  in  the  parts  which  are  involved.  The  gangrene  generally 
begins  in  the  pulp  of  the  terminal  phalanx,  and  either  remains  superfi- 
cial or  the  entire  terminal  phalanx  perishes.  Bramann  saw  this  sym- 
metrical gangrene  develop  in  three  brothers  of  seven,  ten,  and  thirteen 
years  of  age  ;  it  was  probably  the  result  of  syringomyelia.  As  etiological 
factors,  chlorosis,  antemia,  hysteria,  acute  febrile  infectious  diseases 
(typhoid,  intermittent  fever,  etc.),  primary  neuritis,  etc.,  come  into 
consideration.  The  direct  cause  is  probably  an  infection  of  the  cen- 
tral nervous  system,  and  Weiss  states  that  the  preponderance  of  evi- 
dence points  to  vasomotor  disturbances  of  nutrition  in  certain  portions 
of  the  central  nervous  system.  The  acute  gangrene,  originating  from 
disease  of  the  vessels,  is  certainly  to  be  distinguished  from  the  purely 
nervous  symmetrical  gangrene  (Socin). 

Spontaneous  (Angeioneurotic)  Gangrene  of  the  Extremities  occurring 
in  Youth. — In  rare  instances  a  spontaneous  gaiigrene  of  the  extremi- 
ties will  be  observed  which  is  not  due  to  ergotism,  diabetes,  or  syphi- 
lis, and  which,  in  contradistinction  to  sen^Je  gangrene,  affects  strong, 
young  individuals  who  are  not  marasmic  (Billroth,  Braun,  etc.).  The 
course  of  the  disease  is  very  tedious  and  extremely  painful.  In  rare 
cases  spontaneous  recovery  has  been  observed,  but  it  is  generally  the 
best  plan  to  amputate  the  limb,  for  example,  by  Gritti's  method,  at 
the  knee,  or  higher  up,  through  the  thigh.  Attempts  at  amputation 
nearer  the  periphery,  in  close  proximity  to  the  gangrene,  are  usually 
hopeless.  Zoege-Manteuffel  and  others  found  the  causation  of  this 
spontaneous  gangrene  to  be  a  high  grade  of  arterio-sclerosis,  with  nar- 
rowing and  thrombosis  not  only  of  the  main  arterial  trunks  in  the  leg 
but  also  of  the  smaller  veins.  The  principal  nerves  are  usually  much 
thickened  and  swollen.  Angeio-sclerotic  gangrene  is  particularly  apt 
to  occur  in  cold,  northern  regions,  such  as  Russia. 

Symptoms  of  Gangrene. — The  symptoms  of  gangrene  vary  in  general 


§100.j  GANGRENE  (NECROSIS)   OF  THE  SOFT   PARTS.  565 

according  to  its  cause  and  location,  as  well  as  the  kind  of  tissue  which 
is  affected.  We  recognise  a  dry  gangrene — innniitication,  as  it  is  called 
— and  a  moist  gangrene.  In  dry  gangrene  there  is  a  drying  of  the  tis- 
sues as  a  result  of  a  loss  of  water;  gangrajno-senilis  is  an  example  of 
this  form.  In  such  cases  the  superficial  layers  of  tissue  dry  and  form 
a  gangrenous  eschar.  The  moist  gangrene  is  a  necrosis  with  softening 
and  liquefaction,  and  consequently  is  the  opposite  of  dry  gangrene. 
Moist  gangrene  is  particularly  likely  to  be  accompanied  by  decomposi- 
tion. In  such  cases  the  tissues  are  softened  and  discoloured,  and  present 
bluish-red,  green,  or  black  spots ;  they  give  forth  a  penetrating  odour, 
which  is  due  to  the  formation  of  products  consisting  of  compounds  of 
ammonia  and  fatty  acids.  The  epidermis  is  elevated  by  blebs  which 
are  filled  with  a  stinking  liquid.  Not  infrequently  bubbles  of  gas  de- 
velop at  the  same  time  which  contain  especially  ammonia,  volatile  fatty 
acids,  and  sulphide  of  hydrogen.  This  moist  gangrene  with  decompo- 
sition is  particularly  apt  to  take  place  when  the  air  with  its  germs  has 
access  to  the  parts  and  no  disinfecting  antiseptic  dressing  is  employed, 
and  consequently  occurs  most  commonly  in  the  superficial  portions  of 
the  body  and  the  cavities  which  adjoin  in  the  lungs,  etc.  It  is  only 
possible  for  this  gangrene  to  attack  other  organs  by  metastases,  whicli 
are  caused  by  suppurating  thrombi  or  gangrenous  pus  and  the  bacteria 
they  contain. 

The  coagulation  death  is  another  form  in  which  gangrene  presents 
itself.  It  occurs  especially  in  necrosis  of  the  muscles  or  other  tissues 
made  up  of  cells  containing  protoplasm  which  is  capable  of  coagula- 
tion. According  to  Cohnheira  and  Weigert,  it  is  dependent  either 
upon  a  chemical  precipitation  of  an  albuminate  or  upon  coagulation  of 
the  albumen  by  the  action  of  a  ferment  which  is  set  free.  Coagulation 
necrosis  occurs  particularly  in  diphtheria,  croup,  and  in  the  tissues  sur- 
rounding colonies  of  bacteria. 

Cohnheim  states  that  necrosis  very  seldom  results  from  the  action 
of  moulds,  for  the  reason  that  the  mould  fungi  and  the  bacteria  of 
decomposition  do  not  exist  under  the  same  conditions.  A  medium 
which  supports  the  bacteria  of  putrefaction  is  unsuitable  for  mould 
fungi.  The  latter,  for  the  most  part,  are  incapable  of  development  in 
the  living  body,  and  soon  disappear  (see  pages  254-257). 

Other  symptoms  of  gangrene  ai-e  a  loss  of  function  in  the  parts 
affected,  their  insensibility,  and  the  cool  or  cold  feeling  which  they 
exhibit  on  palpation. 

The  microscopic  changes  in  the  dead  tissues  vary  with  the  form  of 
the  necrosis — that  is,  M'hether  they  become  dry  or  undergo  putrefac- 
tion.    In  the   above-mentioned  coagulation  necrosis  of  Weio-ert   the 


566    INJURIES  AND   SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

cell  nuclei  disappear  first.  The  nuclei  are  dissolved  by  the  lymph,  and 
the  suljstance  of  which  they  consist  perhaps  unites  with  the  albuminous 
constituents  of  the  lymph.  This  phenomenon  is  similar  to  the  coagu- 
lation of  fibrin.  The  dead  cells  also  exhibit  a  diminution  in  the  size 
of  the  nuclei,  vacuolar  degeneration,  swelling  of  the  protoplasm  of  the 
cell,  and  a  mei-ging  of  the  borders  of  the  cells  into  the  surrounding 
parts. 

As  regards  the  course  of  the  gangrene,  it  either  remains  limited  to 
a  particular  region,  or  it  spreads.  The  gangrene  following  an  inter- 
ruption of  the  circulation  or  some  direct  traumatic  disturbance  of  the 
tissue  elements  in  an  otherwise  healthy  individual,  ordinarily  remains 
circumscril)ed  uidess  the  gangrenous  focus  becomes  infected  by  bac- 
teria. On  the  other  hand,  if  the  health  of  the  individual  or  of  the 
affected  portion  of  the  body  is  faulty,  the  gangrene  may  spread  (decu- 
bitus, gangraena  senilis,  diabetes  mellitus).  The  infectious  gangrene,  in 
particular,  wliich  follows  the  development  of  bacteria,  is  very  apt  to 
spread  (see  pages  333-337).  The  boundary  of  the  necrosed  tissue  is 
formed  by  the  so-called  line  of  demarcation — that  is,  by  a  demarcating 
inflammation  and  suppuration — by  wliifli  the  living  are  separated  from 
the  dead  parts.  A  loss  of  substance  takes  place— in  other  words,  an 
ulcer  of  the  skin,  the  surface  of  the  ulcer  being  the  seat  of  a  suppura- 
tive inflammation.  This  ulcer  gradually  purifies  itself  and  cicatrises 
by  the  formation  of  granulation  tissue.  Xot  infrequently  when  the 
dead  tissue  is  cast  off,  some  cavity  of  the  body  is  opened,  and  death 
follows.  Thus,  for  example,  perforation  of  the  intestine  or  stomach 
bv  an  ulcer  may  give  rise  to  fatal  peritonitis,  and  caries  and  necrosis 
of  the  petrous  portion  of  the  temporal  bone  may  cause  suppurative 
meningitis  or  a  cerebral  abscess.  Other  dangers  of  gangrene  are  the 
occurrence  of  haemorrhage  fr(jm  the  erosion  of  an  artery,  and  the  de- 
velopment of  some  secondary  infectious- wound  disease,  particularly 
pyaemia  and  septicaemia,  from  infection  by  micro-organisms  and  the 
products  of  their  metabolism. 

The  treatment  of  (janijrene  is  conducted  according  to  the  rules  laid 
down  in  ^§  70,  88,  and  90  to  93,  to  which  we  must  refer  the  reader.  In 
gangrene  of  the  extremities,  amputation  should  not  be  performed  too 
near  the  gangrenous  parts — a  matter  which  has  been  insisted  upon 
Ijefore,  Should  a  gangrene  of  the  foot,  for  example,  involve  the 
dorsum  or  sole  of  the  foot,  Gritte's  operation  should  be  given  the 
preference,  or  amputation  at  the  thigh,  because,  if  the  leg  is  amputated 
below  the  knee,  extensive  gangrene  of  the  flaps  almost  always  occurs.  ^ 


CHAPTER  III. 

INJURIES    AND    SUEGICAL    DISEASES    OF   BONE. 

Injuries  of  bones:  Fractures;  contusions  and  wounds  of  bone;  gunshot  injuries  of 
bone  (see  also  §  124).— The  inflammations  and  diseases  of  bone:  Acute  mflamma- 
tions  of  bone;  acute  periostitis;  acute  osteomyelitis;  acute  ostitis.— Metastatic 
inflammations  of  bone.— Embolic  foreign-body  inflammations  in  mother-of-pearl 
turners  and  workers  in  woollen  and  jute  mills.-The  chronic  inflammations  of 
bone(tuberculosis,  syphilis,  etc.):  Chronic  periostitis,  osteomyelitis,  and  ostitis.— 
Caries— Necrosis  of  bone.— Rhachitis.— Osteomalacia.— Atrophy  and  hypertrophy 
of  bone.-Increased  longitudinal  growth.-Giant  growth.-Acromegaly.-Tumours 
of  bone  (see  Tumours,  Chapter  V).-Parasitic  tumours  of  bone (echinococcus ;  cysti- 
cercus  cellulosae). 

^  §  101.  Fractures.— The  word  fracture  needs  no  further  definition  ;  it 
means  both  the  act  of  breaking  a  bone  and  the  state  of  being  broken. 
Fractures  are  very  common,  and,  according  to  Bruns,  they  make  up 
more  than  a  seventh  part  of  all  injuries  which  come  under  observation, 
and  are  about  ten  times  more  common  than  dislocations. 

Cause  of  Fractures. — Every  fracture  presupposes  the  action  of  some 
mechanical  violence  upon  the  bone  in  question  which  is  great  enough 
to  overcome  the  strength  and  the  power  of  resistance  which  the  bone 
possesses.  The  majority  of  fractures  are  produced  by  external  vio- 
lence ;  and,  according  to  the  way  in  which  the  external  violence  acts,  we 
distinguish  two  main  groups,  the  direct  and  the  indirect  fractures. 

Direct  and  Indirect  Ti&ctwces.— The'' direct  fractures  are  those  in 
which  the  bones  are  broken  at  the  point  where  the  violence,  such  as  a 
blow,  a  thrust,  a  gunshot,  the  wheel  of  a  waggon,  etc.,  is  applied.  If, 
on  the  other  hand,  the  break  is  situated  at  a  point  some  distance  from 
the  place  where  the  violence  has  been  applied— in  a  fall,  for  example— 
we  call  such  a  fracture  sal  indirect  one.  It  is  evident  that  in  the  direct 
fractures  especially  the  soft  parts  will  receive  more  or  less  injury,  which 
varies  from  a  slight  contusion  to  a  complete  mangling  of  all  the  soft 
parts  surrounding  the  broken  bone.  The  indirect  fractures  are  most 
commonly  the  result  of  a  bending  of  the  bone  beyond  the  limits  of  its 
elasticity' by  bringing  the  two  ends  of  the  bone  nearer  together,  as  in 
a  fracture  of  the  thigh  from  a  fall  upon  the  feet.     In  other  instances 

(567) 


568  INJURIES  AND   SURGICAL   DISEASES  OF  BONE. 

indirect  fractures  are  the  result  of  forced  compression  and  crushing,  as 
in  fractures  of  the  vertebrae  from  a  fall  upon  the  buttocks;  or  of  Vio- 
lence applied  through  a  fulcrum  with  crushing,  as  in  fracture  of  the 
olecranon  by  hyperextension  at  tlie  elbow  joint;  or  of  traction,  tear- 
ing, or  rotation  (torsion).  The  lower  end  of  the  radius,  for  example, 
is  caused  to  break  by  the  traction  exerted  by  the  anterior  ligament  of 
the  wrist  in  forced  dorsal  flexion.  Great  interest  attaches  to  the  pro- 
duction of  indirect  fractures  of  the  skull  by  a  tearing  apart  of  the  bony 
parts  which  are  put  on  the  stretch,  or  by  the  vertebrae  being  driven 
into  the  occipital  foramen  (Messerer).  In  indirect  fractures  it  some- 
times happens  that  the  fragments  are  more  or  less  firmly  forced  into 
one  another  (so-called  impacted  fi'actures).  The  injuries  to  soft  parts 
occurring  in  indirect  fractures  are  produced  by  more  or  less  pointed 
fragments  which  perforate  the  skin  (transfixion  fi-actures),  or  wound 
muscles,  vessels,  or  nerves,  etc. 

Fractures  resulting  from  Muscular  Action. — Sometimes  fractures  are 
the  result  of  excessive  muscular  action.  These  usually  take  the  form 
of  a  tearing  oil  of  some  small  bony  prominence,  like  the  coracoid  pro- 
cess of  the  scapula,  or  the  greater  tuberosity  of  the  humerus.  The 
fractures,  which  often  complicate  dislocations,  are  frequently  produced 
in  a  similar  manner ;  for  example,  the  ilio- femoral  ligament  may  tear 
off  a  piece  of  bone  from  the  femur  at  its  point  of  attachment  (cortical 
fracture).  It  only  rarely  happens  that  large,  hollow  bones  are  broken 
by  muscular  traction.  In  this  category  come  the  fractures  of  the  femur 
sustained  in  playing  at  ninepins,  or  in  administering  a  kick  which 
misses  its  object ;  also  fractures  of  the  humerus  from  violent  movements 
of  the  arm,  ti-ansverse  fractures  of  the  patella  (see  Special  Surgery),  and 
fi-actures  of  the  clavicle  from  brandishing  a  whip,  or  fractures  of  the 
ribs  as  a  result  of  violent  attacks  of  coughing  in  old  people,  etc. 

Intra-uterine  Fractures. — Intra-uterine  fractures  in  the  foetus  are 
produced  by  the  infliction  of  great  violence  to  the  abdomen  of  the 
mother.  Varying  with  the  length  of  time  which  elapses  between  the 
reception  of  the  injury  and  the  birth  of  the  child,  the  fracture  will 
be  found  to  be  comparatively  recent,  in  process  of  repair,  or  already 
healed.  '  The  bending  or  fracture  of  bones  due  to  foetal  rhachitis  or 
syphilis  are  not  of  traumatic  origin.  Other  intra-uterine  bony  deform- 
ities are  also  met  with  which  at  first  sight  look  like  badly  united  intra- 
uterine fractures,  but  are,  in  reality, "^defects  in  development.  In  this 
class  of  cases  belong  the  malformations  which  are  the  result  of  defects 
in  ossification,  such  as  al)sence  of  the  fibula,  etc. 

Fractures  during  Birth. — In  other  instances  infants  sustain  fractures 
during  birth  from  unskilful  operative  midwifery  or  "from  the  act  of 


^  101.]  FRACTURES.  569 

parturition  itself.  The  bones  of  the  extremities  may  he  broken  through 
the  diaphysis  or  in  the  region  of  the  epiphysis  while  an  arm  is  being 
freed  or  version  or  extraction  performed,  but  fractures  of  the  bones  of 
the  head  are  mainly  due  to  the  use  of  the  forceps.  In  very  rare  cases 
fractures  of  mal})osed  extremities  result  from  contractions  of  the  uterus. 
The  latter  are  more  likely  to  cause  injuries  to  the  skull,  especially  in 
cases  of  narrow  pelvis  or  anomalies  of  the  child's  liead.  In  the  milder 
cases  there  will  be  a  depression  with  or  without  fissure,  while  in  severe 
cases  actual  fractures  of  the  skull  occur. 

The  amount  of  resistance  of  which  a  bone  is  capable  bears  a  very 
important  relationship  to  the  production  of  fractures.  The  strength  of 
a  bone  varies  greatly  in  different  individuals,  as  does  also  the  strength 
of  different  bones  in  the  same  individual,  and  even  different  parts  of 
the  same  bone  exhibit  variations  in  resisting  power. 

Natural  Solidity  of  the  Bones. — The  natural  strength  and  mechanical 
capabilities  of  bones,  so  important  in  the  etiology  of  fractures,  have  re- 
cently been  investigated  by  P.  Bruns,  Keiff,  and  others,  and  the  attempt 
has  been  made  to  found  the  etiology  of  fractures  upon  a  physical  basis. 
The  elasticity  of  the  individual  bones,  i.  e.,  their  ability  to  resume  their 
original  shape  after  it  has  been  changed  by  external  force,  and  the 
limits  within  which  this  is  possible— in  other  words,  the  limit  of  their 
elasticity— have  been  computed.  The  strength  or  the  resistance  which 
the  bones  offer  to  violence  in  its  various  forms,  such  as  pressure,  trac- 
tion, bending,  rotation,  or  torsion,  has  also  been  ascertained.  It  has 
thus  been  possible  to  determine  definite  values  for  the  elasticity  and 
solidity  of  the  texture  of  the  bone  substance,  and  for  the  bones  in  their 
entirety,  which  values  express  the  amount  of  this  or  that  kind  of  vio- 
lence required  to  produce  fractures  ;  and  hence  it  is  perfectly  correct  to 
desio-nate  fractures  according  to  the  nature  of  the  traumatism,  as  frac- 
tures  from  traction  or  tearing,  from  compression,  bending,  or  torsion. 

fV^  Measurements  showing  the  Strength  of  Bones.— As  regards  the  strength 
of  a  bone  due  to  its  structure,  the  values  naturally  vary  in  different  bones 
and  in  different  individuals,  but  the  general  rule  holds  that  the  compact  bone 
substance  is  always  stronger  than  the  spongy. 

The  tensile  strength  of  the  compact  bone  substance  in  a  fresh  condition 
and  during  middle  life  amounts,  according  to  Rauber  and  Messerer,  to  9 •25 
to  12  ^l  kilogrammes  per  square  millimetre,  or  about  the  same  as  that  of 
brass  and  cast  iron.  .  The  compression  strength  is  still  greater  fl2'56  to  16 "8 
kilogrammes  per  square  millimetre),  or  double  that  of  wood,  granite,  or  lead. 
The  torsion  strength  averages  8  kilogrammes-per  square  millimetre. 

The  strength  of  spongy  bone  substance  is  much  less,  the  compression 
strength  of  the  spongy  portion  of  the  femoral  condyles  amounting,  according 
to  Messerer,  to  only  0*96  kilogramme  per  square  millimetre,  that  of  the  bodies 


570  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

of  the  vertebrce  to  0-84,  being  in  middle  life  0-62  to  0-92,  and  in  old  age 
only  0-22  kilogramme  per  square  millimetre. 

The  strength  of  the  bone  as  a  whole  is  a  matter  of  great  practical  impor- 
tance as  regards  the  etiology  of  fractures.  The  tensile  .sti'ength  of  the  hu- 
merus, for  example,  according  to  Messerer.  amounts  to  533,  and  of  the  femur 
to  694  kilogrammes  per  square  millimetre.  He  found  that  the  compression 
strength  of  the  individual  bones  decreased  in  the  following  order  :  Tibia, 
femur,  humerus,  radius,  ulna,  clavicle,  fibula.  Compression  directed  through 
the  longitudinal  axis  caused  fracture  of  the  shaft,  the  tibia  being  the  strongest 
and  breaking  under  a  pressure  of  1,650  kilogrammes,  the  femur  on  the  aver- 
age in  man  requiring  a  pressure  of  756  kilogrammes,  the  radius  in  man  334 
kilogrammes,  in  women  220  kilogrammes.  Frequently  the  break  does  not 
take  place  at  the  point  most  endangered— the  middle  of  the  bone— but  at  one 
or  other  articular  extremity  by  compression. 

A  great  number  of  fractures  are,  as  is  well  known,  the  result  of  bending 
(Bruns).  The  limit  of  bending  possessed  by  bones  varies  in  different  yeai'S 
of  life,  and,  according  to  Messerer,  it  amounts  to  between  1,040  and  1,980,  and 
reaches  its  maximum  at  middle  age.  In  men  400  kilogrammes,  and  in  women 
263  kilogrammes,  will  cause  a  fracture  of  the  femur  from  bending. 

The  torsion  elasticity  amounts  to  about  a  third  of  the  bending  elasticity. 
A  fracture  of  the  femur  by  torsion,  according  to  Messerer,  is  produced  by  89 
kilogrammes,  of  the  clavicle  by  8  kilogrammes.  The  femur  po.ssesses  the 
greatest  torsion  strength,  the  clavicle,  ulna  and  fibula  the  least. 

Messerer's  experiments  on  the  skull  show  that  the  diameter,  which  is  not 
subjected  to  pressure,  becomes,  in  the  majority  of  instances,  gradually  though 
very  slightly  lengthened  in  proportion  as  the  pressure  increases.  The  de- 
crease of  the  diameter  in  the  direction  of  the  pressure  is  not  evenly  distributed 
over  the  whole  skull,  as  only  the  part  directly  subjected  to  pressure  bends  in- 
wards. The  skull  withstands  a  greater  amount  of  force  in  a  sagittal  than  in 
a  transverse  direction.  The  average  pressure  required  to  produce  a  longi- 
tudinal fracture  avei-aged  650  kilogrammes  ;  for  a  transverse  fracture,  520 
kilogrammes.  In  most  instances  the  base  of  the  skull  proved  to  be  the  weak- 
est spot,  that  portion  of  it  bursting  which  was  under  the  greatest  tension ; 
transverse  pressure  caused  a  transverse  fracture,  and  longitudinal  pressure  a 
longitudinal  fracture.  The  average  pressure,  acting  through  the  vertebi-al 
column,  which  was  required  to  produce  a  fracture  of  the  base  amounted  to 
270  kilogrammes. 

In  young  persons  the  sternum  could  be  di-iven  completely  back  to  the 
vertebral  column  by  sagittal  pressure  upon  the  thorax  without  producing  a 
fracture.  A  pressui'e  of  250  kilogrammes  exerted  in  a  sagittal  direction  upon 
the  pelvis  generally  caused  a  symmetrical  fracture  of  the  os  pubis  ;  a  trans- 
verse pressure  of  180  kilogrammes  exerted  upon  the  crest  of  the  ilium,  caused 
a  diastasis  of  the  sacro-iliac  joint. 

According  to  Rauber.  the  strength  of  bones  is,  as  a  general  thing,  dimin- 
ished by  heat. 

Changes  in  the  Strength  of  the  Bones. — The  normal  strength  of  bones 
is  affected  very  materially  by  various  circumstances,  such  as  their  shape, 
their  length  and  thickness,  the  direction  of  their  longitudinal   axes, 


i^lOl.]  FRACTURES.  '  571 

wliether  the  latter  approach  the  pcrpcmiicular  or  show  deviations 
from  it,  etc.  There  are  also  various  patholo^^ical  conditions  which 
lessen  the  resisting  i)owers  of  hones  and  produce  an  abnormal  fragility 
(osteopsathyrosis),  causing  the  bones  to  break  spontaneously  or  upon 
the  application  of  a  very  slight  amount  of  violence.  In  this  category 
belongs  the  atrophy  of  bone  which  occurs  in  advanced  age,  or  in  the 
course  of  chronic  diseases,  or  after  paralysis,  etc.  The  strength  of  the 
bones  usually  increases  till  middle  life,  and  from  then  on  gradually 
decreases  (senile  atrophy).  •'  The  bones  also  atrophy  when  they  are  not 
used,  as  in  the  course  of  chronic  diseases,  in  paralysis,  etc.  (atrophy 
of  disuse). 

Neurotic  or  Tropho  neurotic  Atrophy. — In  addition  to  the  atrophies 
of  senility  and  disuse,  AVeir  Mitchell,  Charcot,  and  P.  Bruns  have  di- 
rected attention  to  the  occurrence  of  neurotic  or  tropho-neurotic  atro- 
phies of  bone  which  are  due  to  affections  of  the  central  nervous  system. 
In  this  class  of  cases  belongs  the  fragility  of  bone  which  accompanies 
tabes  dorsalis  and  chronic  cerebral  disease,  such  as  progressive  paralysis, 
and  in  fact  all  forms  of  mental  disease  and  paralysis.  Eauber  found 
that  the  tibia  of  a  paralysed  extremity  supported  a  weight  of  198 
grammes,  while  the  bone  on  the  non-paralysed  side  held  a  weight  of 
281  grammes. 

Ko  further  explanation  is  required  for  the  fragility  which  is  the 
result  of  disease  of  bone  with  subsequent  loss  of  substance,  such  as 
occurs,  for  example,  in  tubercular  and  syphilitic  diseases,  suppuration, 
or  necrosis ;  tumours,  such  as  cysts,  sarcoma,  or  carcinoma  ;  from'  the 
presence  of  echinococcus ;  or  abnormal  softness  of  structure  (rhachitis 
and  osteomalacia).  An  abnormal  weakness  and  fragility  of  the  bones  is 
also  present  in  scurvy,  a  disease  which  was  at  one  time  very  common. 

Idiopathic  Osteopsathyrosis. — But  in  addition  to  these  various  kinds 
of  fragility  of  bone  due  to  this  or  that  cause,  there  is  also  an  idiopathic 
form,  the  etiology  of  which  is  as^yet  completely  unknown.  In  such 
patients,  who  in  all  other  respects  seem  perfectly  well,  the  slightest  ex- 
hibition of  violence,  such  as  a  sudden  movement,  a  slight  thrust,  or  even 
turning  over  in  bed,  suffices  to  produce  a  fracture  of  bones  which  ex- 
ternally appear  entirely  normal.  The  malady  is  congenital  in  a  num- 
ber of  cases,  and  sometimes  a  pronounced  hereditary  taint  runs  through 
many  generations.  In  other  cases  the  disease  develops  in  early  youth 
or  later,  and  then  usually  persists  throughout  life.  In  this  idiopathic 
form  of  fragility  no  gross  changes  are  found  in  the  bones.  The  most 
probable  cause  of  this  disturbance  of  the  nutrition  of  the  bones  is  a 
change  in  the  composition  of  their  ground  substance.  The  observa- 
tions of  Blanchard,  in  particular,  show  the  frequency  of  fractures  in 


572  INJURIES   AND   SURGICAL   DISEASES   OP   BONE. 

individuals  with  idiopathic  fragilitas  ossium.  He  liad  one  case  of  a 
tvvelve-and-a-half-year-old  girl  who  had  had,  since  the  second  month  of 
her  existence,  forty-one  fractures  from  the  effects  of  very  slight  violence  ; 
she  had  had  fourteen  fractures  of  the  right  and  eleven  of  the  left  leg. 
Arnott  had  a  patient  fourteen  years  old  who  since  the  third  year  of 
life  had  had  thirty-one  fractures,  of  wdiich  seven  were  of  the  right  thigh 
and  nine  of  the  right  leg  below  the  knee.  It  is  rather  remarkable  that 
the  repair  of  fractures  in  idiopathic  osteopsathyrosis  usually  takes  place 
easily  and  quickly. 

Strength  of  the  Epiphyses. — As  long  as  the  diajjhysis  and  the  epiph- 
ysis, during  the  period  in  which  the  bones  are  growing,  are  con- 
nected by  a  cartilaginous  symphysis,  the  resistance  at  this  point  may  be 
diminished  by  various  processes,  especially  those  of  an  inflammatory 
nature,  and  a  spontaneous  separation  of  the  epiphysis  may  thus  be  pro- 
duced. Under  this  heading  came  the  epiphyseal  separations  due  to 
syphilitic  processes,  to  scurvy,  and  to  the  primary  infectious  inflamma- 
tions of  the  bone  marrow  (osteomyelitis). 

The  Various  Kinds  of  Fractures — Incomplete  Fractures,  Depressions, 
Fissures. — We  distinguish  complete  and  incomplete  fractures  according 
to  the  extent  to  which  the  bone  is  divided.  To  the  incomplete  fractures 
belong  the  green-stick  fractures  and  the  fissures.  A  green-stick  frac- 
ture occurs  in  the  bending  of  a  bone,  by  which  the  cortical  substance 
on  the  convex  side  is  broken  while  on  the  concave  side  it  is  only  pressed 

in  (Fig.  331).     The  depressions  oc- 
curring on  the  skull,  for  example,  as 
a  result  of  pressure  or  a  blow,  can 
Fi3.  33i.-ineompiete  fracture  (green  stick    jjg  regarded  as  incomplete  fractures 

iracture)  oi  the  clavicle.  o  ,  x 

(Fig.  340).  ■  The  fissures  (Fig.  332) 
are  comparable  to  a  crack  in  a  glass  or  a  plate,  and  occur  especially  in 
the  brittle  bones  of  adults,  less  often  in  those  of  children,  and  are  fre- 
quently combined  with  complete  fractures  which  are  received  at  the 
same  time.  They  are  particularly  common  on  the  skull.  In  gunshot 
fractures  the  bones  involved  often  sustain  numerous  fissures.  It  is  of 
great  practical  importance  to  note  that  fissures  of  this  description, 
especially  when  the  fracture  is  near  a  joint,  sometimes  run  through  the 
articular  extremity  of  the  bone  and  penetrate  into  the  neighbouring 
joint.  If  after  a  gunshot  fracture,  for  example,  suppuration  should 
take  place  at  the  point  wdiere  the  bone  has  been  broken,  this  suppura- 
tion may  travel  along  the  fissure  into  the  joint. 

Complete  Fractures. — A  fracture  is  complete  when  the  bone  breaks 
into  two  or  more  pieces  which  are  completely  separated  from  one 
another;  division  of  the   bone  into  two*  fragments  takes  place  most 


§  101.] 


FRACTURES. 


573 


commonly.  According  to  the  direction  of  the  line  of  fracture  with 
reference  to  the  longitudinal  axis  of  the  bone  we  recognise  transverse, 
oblique,  s])iral,  and  longitudinal  fractures.  The 
pure  transverse  fractures  are  generally  jDroduced 
by  direct  violence,  and  are  not  very  common  if 
we  disregard  the  separations  of  the  epi})hyses. 
The  most  common  fractures  are  the  oblique, 
which  are  almost  always  the  result  of  indirect 
violence  or  forcible  bending.  The  fracture  hav- 
ing the  form  of  a  clarinet  mouthpiece,  and  first 
described  by  French  writers  {^fracture  en  hec  de 
flute)^  is  a  pronounced  oblicpie  fracture  which 
occurs  especially  in  the  tibia  and  femur,  and 
was  produced  by  W.  Koch  by  rotation  combined 
with  a  vertically  directed  blow  (Fig.  333).  The 
spiral  or  torsion  fracture  (Figs.  334,  335)  is 
produced,  according  to  the  experiments  of  Koch 
and  Bruns,  exclusively  by  twisting,  the  line  of 
fracture  having  the  shape  of  a  spiral  curve. 
The  prognosis  of  a  spiral  fracture  is  more  un- 
favourable than  an  oblique  one,  for  the  reason 
that  the  fractured  surfaces  are  very  extensive 
and  the  points  of  one  of  the  fragments  may 
readily  penetrate  the  skin  or  be  driven  into  the 
other  fragment  and  cause  considerable  crushing  of  the  bone  marrow. 

Longitudinal  Fractures. — Longitud- 
inal fractures,  or  the  division  of  a  bone 
into  two  fragments  with  the  line  of 
fracture  running  its  entire  length,  are 
very  rare  in  the  long,  hollow  bones, 
and  most  longitudinal  fractures  are 
merely  extreme  forms  of  oblique  frac- 
tures. Kronlein  has  described  a  longi- 
tudinal fracture  of  the  humerus  and 
three  longitudinal  fractures  of  the 
phalanges  of  the  fingers,  and  he  could 
find  in  literature  only  one  longitudinal 
fracture  through  the  whole  length  of 
the  tibia,  which  was  recorded  by  Gii- 
diicke.  Longitudinal  fractures  have 
been  noted  somewhat  more  frequently  in  the  short  bones  (patella,  ver 
tebrse). 


Fig. 


332.— Fissures 
t'eiiiur. 


the 


Fig.  333. — Fracture  havinof  the  shape  of 
tlie  mouth-piece  of  a  nute  {fracture 
en  hec  de  fiute). 


57-i 


INJURIES   AND  SURGICAL  DISEASES  OF   BONE. 


A  Multiple  Fracture. — In  a  multiple  fracture  (fractura  multiplex) 
the  bone  is  eitlier  broken  at  two  or  tLree  different  points  Cdouble,  three- 
fold fracturej,  or  the 
bone  is  shattered  at 
one  point  into  many 
fragments  (commi- 
nuted fracture — frac- 
tura comminuta.j 
TJie  term  multiple 
fracture  also  includes 
fractures  sustained 
simultaneously  by 
several  bones,  partic- 
ularly those  Avliich  are 
placed  parallel  to  one 
another  in  the  fore- 
arm and  leg.  The 
shape  of  the  multiple 
breaks  in  the  same 
bone  varies,  of  course, 
very  much,  but  a  few 
typical  forms  are  fre- 
quently observed. 
These  typical  forms 
include  especially  the 
T-  and  Y-shaped  frac- 
tures, occurring  at  the  epiphy.?eal  extremities  of  the  long  bones  (Figs. 
336,  337>  In  the  T  fracture  (Fig.  33G)  there  is  a  transverse  and 
a  longitudinal  break;  in  the  Y  fracture  two  obhqiie  breaks,  the  pro- 
duction of  which  has  been  studied  experimentally  by  Gurlt,  Madelung, 
and  Marcuse.  In  fractures  from  bending  and  from  torsion  a  cuneiform 
or  rhombic  piece  is  sometimes  broken  out  of  the  continuity  of  the  bone 
(Bruns).  The  outward  appearance  of  a  comminuted  or  splintered  frac- 
ture (Fig.  338;  presents  great  variations  in  regard  to  the  number,  shape, 
and  size  of  the  individual  fragments.  In  the  worst  cases  there  will  be 
found  at  the  point  of  fracture  a  peculiar  soft  bag  of  skin  like  a  sack 
filled  with  crepitating  fragments  of  bone,  or  the  bones  and  soft  parts 
are  crushed  into  a  bloody  pulp,  as  is  the  case,  for  example,  in  "run- 
over"  accidents. 

Condition  of  the  Soft  Parts  in  the  JTeighbouihood  of  a  Fracture. — 
The  condition  of  the  soft  parts  in  the  neighbourhood  of  a  fracture  is 
exceedingly  important  for  the  prognosis.     All  fractures  in  wliich  there 


Fk-.  ::4.— Spiral  fracture 
of  the  tibia  (W.  Koch). 


Fig.  3-35. — Spiral  fracture  of  the 
femur  ( W.  Koch;. 


§101.] 


FRACTURES. 


575 


is  a  wound  of  the  soft  parts  penetrating  to  the  line  of  fracture  are  called 
compound  or  open  fractures,  and  must  be  carefully  distinguished  from 


Fia.  o-vi. — T-tihaped  f'raeture 
of  the  lower  end  of  tlio 
femur,  caused  by  a  fall 
upon  the  knee  (liruus). 


Fni.  337.— Y-shaped  fracture 
of  the  condyles  of  the  hu- 
merus, caused  bv  a  fall 
upon  the  elbow  (liruns). 


Fig.  338. — Comminuted  frac- 
ture of  the  lower  cud  ot 
the  liumerus,  caused  by 
a  fall  upon  the  elbow. 


tlie  subcutaneous  or  simple  fractures — i.  e.,  those  in  which  the  outer 
covering  of  the  soft  parts  has  not  been  opened.  In  the  days  before 
antisepsis  the  compound  or  open  fractures  very  often  terminated  fatally 
from  pytemia  and  septicaemia.  The  extent  of  the  wound  of  the  soft 
parts  varies  from  an  insignificant  puncture  to  an  extensive  crushing 
and  laceration  of  the  tissues.  The  wound  is  produced  either  by  the 
same  violence  that  produces  the  fracture,  as  in  gunshot  or  run-over 
injuries,  or  the  skin  is  opened  afterwards  by  injudicious  movement  of 
the  fractured  extremity — in  transportation  of  the  patient,  for  example 
— or  as  a  result  of  gangrene,  etc.  The  open,  comminuted  fractures, 
the  compound  fractures  of  joints,  particularly  those  found  in  gunshot 
wounds,  and  extensive  mangling  of  the  bones  and  soft  parts  in  run-over 
accidents,  are  the  most  unfavourable  compound  fractures. 

Separations  of  the  Epiphyses. — In  young  subjects,  as  long  as  the 
diaphysis  and  epiphysis  are  connected  by  a  cartilaginous  symphysis, 
traumatic  separations  of  the  epiphyses  may  occur,  which,  according  to 
Bruns,  are  most  common  in  the  case  of  the  lower  epiphysis  of  the 
femur,  then  in  the  lower  epiphysis  of  the  radius  and  in  the  upper 
epiphysis  of  the  humerus.  The  >ipontaneoHs  separations  of  the  epiphy- 
ses in  consequence  of  inflammatory  or  suppurative  processes  must  be 
carefully  distinguished  from  the  traumatic  separations.  The  traumatic 
separations  are  mainly  the  result  of  exaggerated  movements  in  joints. 
As  a  result  of  these  exaggerated  movements  in  adults,  dislocations  of 
the  joints  take  place,  but  in  children  fractures  through  the  fragile 
epiphyseal  cartilage  or  in  its  neighbourhood.  This  is  the  reason  why 
traumatic  dislocations  are  so  very  rare  in  young  cliildren.     In  infants, 


576 


INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 


separations  of  the  epiphyses,  particularly  inter  partum,  are  brought 
about  by  violent  or  unskilfully  performed  obstetrical  operations  (turn- 
ing, extraction).  The  age  limit  within  which  epiphyseal  separations 
may  occur  varies  with  the  different  epiphyses.  The  observations  hith- 
erto recorded,  for  example,  show  that  the  twenty-fifth  year  of  life  is 
the  latest  period  at  which  a  traumatic  separation  occurs  in  the  upper 
epiphysis  of  the  humerus. 

Symptomatology  and  Clinical  Course  of  Fractures. — The  symptoms  of 
fractures  are  partly  objective  and  partly  subjective.     The  most  impor- 
tant objective  symptoms  are :  1.  The  abnormal  mobility  of  the  bone. 
2.  Crepitation — i.  e.,  the  rubbing  sound  which  is  heard,  or,  more  cor- 
rectly, felt,  when  the 

'^  ^^~ ^"^     fractured  surfaces  are 

rubljcd  together.  3. 
The  deformity  of  the 
broken  bone,  or  rather 
of  the  part  of  the 
body  to  whicli  it  be- 
longs, in  consequence 
of  the  displacement  of 
the  fragments.  Ab- 
normal mobility  and 
crepitation  are  best 
demonstrated  by  seiz- 
ing both  fragments  in 
the  neighbourhood  of 
the  line  of  fracture 
and  moving  them  in  opposite  directions.  Kotary  movements  may  also 
be  tried  in  cases  of  fractures  of  the  articular  ends  of  bones.  Abnor- 
mal mobility  and  crepitation  are  absent  in  impacted  fractures, 'in  frac- 
tures with  sharp,  toothed  fragments  which  interlock,  and -in  incom- 
plete fractures.  Crepitation  will  also  be  absent  when  the  fractured 
surfaces  are  not  in  immediate  contact  with  one  another.  The  soft 
friction  sound  which  is  sometimes  emitted  by  dried  extravasations  of 
blood  or  by  inflammatory  processes — of  the  tendon  sheaths,  for  ex- 
ample— must  be  carefully  distinguished  from  the  harder  bony  crepi- 
tus. Deformity  is  caused  by  the  displacement  of  the  fragments.  "We 
recognise  the  following  four  principal  kinds  of  displacement,  which 
sometimes  occur  separately  and  sometimes  combined  in  various  ways : 
1,  Angular  displacement  (dislocatio  ad  axin,  Fig.  339,  a) ;  2,  lateral 
displacement  (dislocatio  ad  latus.  Fig.  339,  h) ;  3,  displacement  of  the 
fragments  in  a  longitudinal  direction  (dislocatio  ad  longitudinem,  Fig. 


Fig.  330.— The  differenl  varieties  of  displacements  of  tlie  frag 
iiients. 


a 


«;  101.]  FRACTURES.  577 

389,  c) ;  and,  4,  rotation  of  tlie  fragments  on  tlieir  longitudinal   axis 

(dislocatio  ad  periplicriani).     The  so-called  overriding  of  the  fragments 

— the  pushing  of  one  over  the  other  (Fig.  839,  d) — is  a  combination 

of  the  dislocatio  ad  hitus  and  ad  axin,  bometinics  with  the  addition  of  a 

dislocatio  ad  Idii- 

gitudinem.      The  j^ 

80-called  diastasis         ^^| 

of  the  fragments       ^|P^ 

(Fig.  339,  e)  and      ^P^ 

the  reverse  or  im-     ^Bi 

paction     of     the     ^Hl^^ 

fragments  are  to     ^^BJL 

be  regarded  as  a      ^^^| 

dislocatio  ad  Ion-       ^^^ 

gitudinem.   There     Fio.  340.— a,  Fracture  of  the  skull  -.vith  depression,  seen  from  the  out- 
ic     Q      TrQfiQf^T     r-f  side  (caused  bv  a  fall  upon  a  pointed  stt)ne) ;  6,  the  same  fracture 

lb     d      Vdriery      Ol  ^^^^  jyom  within  (Bergmaun). 

displacement,  oc- 
curring mainly  in  fractures  of  the  skull,  which  is  called  depression  of 
the  fragments  (Fig.  340,  a.  h). 

The  different  displacements  are  sometimes  primary  and  produced 
by  the  fracturing  force,  and  at  other  times  secondary,  occurring  sooner 
or  later  after  the  injury  as  a  result  of  voluntary  or  involuntary  muscu- 
lar contractions,  of  transportation,  examination,  the  position  the  injured 
member  is  caused  to  assume,  of  defective  dressings,  etc.   v 

Subjective  Symptoms  of  Fracture — Pain  and  Disturbance  of  Function. 
— The  subjective  symptoms  of  fracture  are  pain  and  disturbed  function. 
By  pain  is  understood  primarily  the  great  tenderness  of  the  bone  at  the 
line  of  fracture,  especially  when  pressure  is  applied  at  this  point.  Above 
and  below  the  line  of  fracture  the  bone  is  not  at  all  tender  on  pressure. 
This  linear  character  of  the  pain,  so  to  speak,  is  of  diagnostic  impor- 
tance in  doubtful  cases. 

The  disturbance  of  function  which  occurs  in  fractures  needs  no  fur- 
ther explanation.  In  consequence  of  the  division  of  the  bone,  an  ex- 
tremity, for  example,  loses  its  bony  support,  and  the  muscles  their  fixed 
points  of  attachment.  The  amount  of  functional  disturbance  depends 
principally  upon  the  amount  of  the  abnormal  mobility,  displacement, 
and  deformity,  and  also  upon  the  nature  and  location  of  the  fracture. 
If,  for  instance,  only  one  bone  is  broken  in  a  limb  which  contains  two, 
the  functional  disturbance  may  be  very  slight,  varying  with  the  impor- 
tance of  the  broken  bone.  Thus  in  fractures  of  the  fibula  the  patient 
will  still  be  able  to  walk,  and  in  fractures  of  the  ulna  use  of  the  fore- 
arm is  possible,  especially  pronation  and  supination.  The  disturbance 
37 


578  INJURIES  AND  SURGICAL   DISEASES  OP  BONE. 

of  function  is  also  slight  in  the  case  of  impacted  fractures,  and  patients 
with  an  impacted  fracture  of  the  neck  of  the  femur  can  stand  and  walk. 
Moreover,  in  impacted  fractures  of  the  articular  extremities  of  other 
bones  the  mobility  of  the  joint  involved  is  often  very  little  or  not  at 
all  disturbed. 

Fever  in  Subcutaneous  Fractures. — Apart  from  these  local  symptoms 
at  the  point  of  fracture,  we  sometimes  observe  fever  following  the  re- 
ception of  subcutaneous  fractures.  The  thermometrical  measurements 
made  by  Yolkmann,  P.  Bruns,  Grundler,  and  myself,  show  that,  as  a 
rule,  more  or  less  fever  exists,  particularly  during  the  first  few  days 
after  the  injury.  The  height  of  the  fever  varies  between  101-3°  and 
102"2°  F.,  though  in  rare  instances  the  temperature  may  rise  to  104°  F. 
In  twenty-five  out  of  twenty-six  cases  of  subcutaneous  fracture  Grundler 
observed  a  rise  of  temperature  to  99*1°  F.  The  cause  of  this  febrile 
movement  is  ascribed  by  Bergmann,  Wahl,  and  Angerer  to  the  ab- 
sorption of  dead  tissue  elements,  and  especially  of  fibrin  ferment  and 
other  ferments  which  are  formed  in  the  extravasated  blood  near  the 
point  of  fracture,  as  described  in  §  62.  The  fever  is  essentially  a  fer- 
ment intoxication. 

Suppuration  in  Subcutaneous  Fractures. — As  a  rule,  subcutaneous  frac- 
tures heal  without  suppuration,  and  the  latter  only  occurs  when  micro- 
organisms gain  access  to  the  point  of  fracture  through  some  small  cuta- 
neous wound  or  through  the  blood  ;  the  extravasated  blood  and  the 
injured  (necrotic)  tissues  furnish  a  favourable  nutritive  medium  for 
their  development. 

Course  of  Compound  Fractures. — The  course  of  compound  fractures 
varies  greatly,  according  to  the  size  of  the  wound  in  the  soft  parts,  the 
condition  of  the  fragments,  and  the  treatment.  The  favourable  cases 
are  those  with  a  small  cutaneous  wound,  which,  before  infection  occurs, 
heals  by  immediate  adhesion  of  the  opposed  wound  surfaces,  or  beneath 
a  scab  jper  primam  intentionem.  Under  these  conditions  they  run  a 
course  like  that  of  a  subcutaneous  fracture. 

The  worst  cases  of  compound  fractures  are  those  in  which  the  soft 
parts  are  so  extensively  destroyed  that  the  preservation  of  the  limb  is 
entirely  out  of  the  question.  To  these  may  be  added  the  cases  in  whjch 
there  is  extensive  splintering  of  the  bones  or  a  perforation  into  a  joint 
or  one  of  the  cavities  of  the  body.  But  as  a  general  thing  it  is  more  the 
extent  of  the  injury  to  the  soft  parts  than  the  nature  of  the  injury  sus- 
tained by  the  bones  which  determines  the  severity  of  the  case.  Any 
simple  division  of  the  bone  which  is  accompanied  by  great  destruc- 
tion of  soft  parts  is  to  be  regarded,  in  point  of  prognosis,  as  a  more 
severe  injury  than  a  splintering  of  bone  which  is  in  itself  considera- 


g  101.]  FRACTURES.  579 

ble  but  is  not  accoinpiuiled  by  any  great  amount  of  injury  to  the  soft 
parts. 

The  cHuical  course  of  a  compound  fracture  is,  moreover,  affected  ip. 
a  very  marked  degree  by  the  way  in  which  it  is  treated.  The  sooner  a 
compound  fracture  is  placed  under  tlie  protection  of  antiseptic  treat- 
ment— i.  e.,  the  sooner  the  wounded  soft  parts  and  the  seat  of  the  frac- 
ture are  thoroughly  disinfected,  the  drainage  of  the  wound  attended  to, 
and  an  antiseptic  dressing  applied— the  sooner  is  a  satisfactory  course 
of  repair  guaranteed. 

If  we  leave  out  of  consideration  the  compound  fractures  which  heal 
antiseptically,  the  local  symptoms,  in  the  majority  of  cases,  consist  in  a 
more  or  less  severe  iiiilammatory  swelling  in  the  parts  surrounding  the 
wound  and  point  of  fracture.  The  discharge  from  the  wound  is  at  first 
thin  and  discoloured  by  blood.  In  the  aseptic  cases  it  is  limited  in 
amount  and  does  not  become  suppurative.  In  the  cases  which  do  not 
run  an  aseptic  course  the  discharge  is  plainly  purulent  or  even  sanious — 
in  other  words,  it  undergoes  decomposition  in  consequence  of  infec- 
tion by  micro-organisms.  The  production  of  suppuration  and  putre- 
faction is  favoured  by  extensive  destruction  of  the  soft  parts  at  the 
time  of  the  injury.  This  putrefactive  suppuration  can,  if  the  escape  of 
the  discharge  is  prevented,  readily  take  on  a  spreading  character  in  the 
shape  of  a  progressive  gangrenous  cellulitis,  which  may  endanger  the 
preservation  of  the  limb  and  of  life.  If  the  suppuration  or  putrefac- 
tion runs  a  favourable  course,  the  surface  of  the  wound  gradually 
"  purifies  "  itself — i.  e.,  the  superficial  gangrenous  portion  of  the  wound 
is  slowly  cast  off  by  a  demarcating  suppuration,  red  granulations  make 
their  appearance,  and  the  wound  fills  with  germinal  tissue  which  then 
ossifies.  The  suppuration  around  the  ends  of  the  fragments  which 
liave  become  necrotic,  or  around  splinters,  is  sometimes  very  tedious, 
and  there  is  always  the  possibility  of  the  pus  burrowing  or  giving  rise 
to  infectious  suppuration  in  the  periosteum  or  the  bone  marrow,  or 
causing  lymphangitis,  phlebitis,  etc.,  and  thus  death  from  septicaemia 
or  pyaemia.  By  long  confinement  to  bed,  or  from  protracted  fever  or 
profuse  suppuration,  the  patient  may  become  so  exhausted  and  such 
serious  degenerations  of  the  internal  organs  may  occur,  that  life  is  im- 
perilled. 

Throughout  the  entire  period  occupied  by  the  process  of  repair, 
the  temperature  of  the  patient  should  be  taken  two  or  three  times  a 
day,  and  at  every  new  rise  of  temperature  the  wound  should  be  care- 
fully examined  to  determine  the  presence  of  any  disturbance,  such  as  a 
burrowing  of  pus,  a  deeply  located  spreading  inflamm.ation  and  suppu- 
ration, etc. 


580  INJURIES  AND  SURGICAL   DISEASES  OF  BONE. 

Not  infrequently,  after  a  compound  comminuted  fracture  has  healed, 
fistulse  will  persist  for  a  long  time ;  they  indicate  the  presence  of  some 
encapsulated,  necrotic  piece  of  bone — a  so-called  sequestrum. 

Condition  of  the  Urine  in  Fractures.— As  a  result  of  the  absorption  of 
blood  from  the  point  of  fracture,  the  urine  very  frequently  contains  urobilin, 
a  derivative  of  the  colouring  matter  of  blood,  which,  on  siiaking  the  urine 
with  a  solution  of  chloride  of  zinc  and  ammonia,  causes  the  urine  to  assume 
a  yellowish-gi'een  fluorescence.  Fat  is  also  very  often  found  in  the  urine;  it 
is  derived  as  fluid  fat  from  the  crushed  medullary  portion  of  the  bone  and 
the  fat  in  the  neighbouring  soft  parts,  and,  passing  through  the  circulation, 
is  excreted  by  tlie  kidneys.  We  shall  learn  further  on  that  it  can  sometimes 
accumulate  to  a  dangerous  degree  in  the  lungs  and  brain.  The  amount  of 
fat  in  the  urine  varies  greatly,  depending  upon  the  severity  of  the  injury  to 
the  marrow  and  soft  parts;  in  some  cases  it  is  found  only  in  traces,  while  in 
others  there  may  be  large  quantities  of  it.  Occasionally  it  is  so  abundant 
that  it  is  visible  in  the  form  of  smaller  or  larger  drops  on  the  surface  of 
the  virine.  Most  commonly  the  fat  is  mixed  with  the  urine  in  the  form  of  an 
emulsion,  and  Scriba  maintains  that  this  occurs  in  almost  every  case  of  frac- 
ture. After  the  urine  has  been  allowed  to  stand  for  some  time  a  white  layer 
develops  on  its  surface,  which  the  microscope  shows  is  made  up  of  small  and 
minute  fat  drops.  According  to  Scriba,  the  excretion  of  fat  by  the  kidneys 
takes  place  periodically,  corresponding  to  the  sweeping  away  of  the  fat  emboli 
in  the  lungs.  This  is  the  reason  why  the  urine  during  the  repair  of  a  frac- 
ture changes  so  much,  containing  fat  for  several  days  and  then  being  free 
from  it  for  five  to  six  to  ten  days.  The  excretion  of  fat  begins  on  the  second 
to  the  fourth  day  after  the  injury,  and  usually  ceases  on  the  twentieth  to  the 
twenty-fourth  day. 

In  addition  to  fat,  the  urine  of  patients  with  fi-actures  sometimes  contains 
albumen  and  casts.  The  amount  of  albumen  and  casts  is  greatest  in  the  first 
twenty-four  to  forty-eight  hours,  and  the  condition  lasts  about  four  to  six 
days.  Besides  hyaline  casts  Riedel  found  other  casts  studded  with  numerous 
brown  granules  like  those  which  occur  in  bilious  pneumonia  and  other  dis- 
eases accompanied  by  degenerative  changes  in  the  blood.  These  brown  casts 
are  irregular  in  their  occurrence  in  fractures  and  are  frequently  entirely  ab- 
sent, while  in  other  instances  they  appear  in  great  numbers.  Eiedel  ascribes 
the  origin  of  these  brown  casts  to  the  absorption  of  red  blood-corpuscles  at 
the  point  of  fracture.  They  are  obtained  experimentally  by  producing  frac 
tures  artificially,  by  injecting  blood  into  the  peritoneal  cavity,  and  by  inject- 
ing Kohler's  fibrin  ferment.  Both  Orth  and  myself  have  occasionally  found 
very  large  collections  of  red  corpuscles  and  of  the  colouring  matter  of  blood 
in  the  lymph  glands  and  in  the  internal  organs.  The  hEematogenous  jaun- 
dice which  sometimes  occurs  is  similarly  explained  by  the  presence  of  disin- 
tegrated red  corpuscles  and  blood- colouring  matter  in  the  circulation. 

Repair  of  Fractures. — Fractures  either  heal  jpcr  jprimam  or  jpei'  se- 
cundmn  intention  em.,  in  the  same  way  as  described  in  §  61  for  wounds 
of  soft  parts.  Subcutaneous  fractures,  as  a  rule,  heal  ])er  jpinmam  in- 
tentionem,  while  compound  fractures  heal  per  secxmdam,  intentionenn. 


§  101.] 


FRACTURES. 


581 


As  we  remarked  above,  suppuration  takes  place  in  exceptional  cases  of 
subcutaneous  fractures  from  the  entrance  of  niicro-or'::anisnis  through 
an  abrasion  in  the  skin  or  by  means  of  the  blood-vessels. 

Whether  a  fracture  heals  with  or  without  suppuration,  the  anatom- 
ical changes  are  essentially  the  same,  and  consist,  briefly  speaking,  in 
the  formation  at  the  point  of  fracture 
of  cellular  tissue,  which  is  at  first  soft, 
and  later  is  gradually  changed  into 
bone  by  the  ossifying  action  of  the  pe- 
riosteum and  marrow.  The  ossifying 
tissue  at  the  point  of  fracture  is  called 
the  caUus. 

Anatomical  Changes  in  the  Formation 
of  the  Callus. — The  anatomical  changes 
which  take  place  in  the  formation  of 
the  callus  are  histologically  an  ossify- 
ing periostitis  and  osteomyelitis.  The 
extravasated  blood  at  the  point  of  frac- 
ture plays  no  active  part  in  the  forma- 
tion of  the  callus,  and  is  gradually  sup- 
planted by  a  germinal  tissue  rich  in  cells 
and  vessels.  The  outer  or  periosteal 
callus  originates  from  the  inner  layer 
of  periosteum,  which  contains  osteo- 
blasts, while  the  marrow  forms  the  in- 
ner or  medullary  callus  (Fig.  341).  The 
callus  between  the  broken  ends  of  the 
bone  is  called  the  intermediary  callus, 
and  is  mainly  produced  by  proliferation 
of  the  periosteal  germinal  tissue  be- 
tween the  fractured  surfaces ;  the  tissue 
of  the  opened  Haversian  canals  and  the 
marrow  only  shares  to  a  slight  extent  in  the  formation  of  the  interme- 
diary callus.  The  view  which  formerly  prevailed — namely,  that  the 
surrounding  soft  parts  were  capable  of  contributing  to  the  formation 
of  the  outer  callus — is  untenable  in  the  light  of  our  present  knowledge 
of  the  normal  development  of  bone. 

The  Normal  Formation  of  Bone — The  Development  of  Bone. — It  is 
now  generally  believed  that  the  normal  development  of  bone  is  mainly 
the  result  of  successive  appositions  of  bone  substance  due  to  the  activ- 
ity of  the  medullary  tissue,  the  cells  of  which  change  into  specific  bone- 
forming  cells — the  so-called  osteoblasts  (Gegenbaur,  Fig.  342). 


E     M 

Fig.  341. — Longitudinal  section  throusrh 
a  fracture  of  the  femur  three  weeks 
old  :  P=  periosteum  :  K  =  bone  ; 
J/=medulla.  Periosteal  callus  and 
medullary  callus.  The  intermedi- 
ary callus  consisting  of  periosteal 
granulation-tissue, "which  is  ossitled 
only  in  some  places  and  is  partly 
cartilaginous. 


/%:; 


;v- 


5S2  IXJURIES  AND  SURGICAL  DISEASES   OF  BONE. 

The   medullary  tissue  may  spring  either  from  the  periosteum  or 
from   cartilage.     The  periosteum  or  perichondrium  (in  the  cartilagi- 
nous bones  of  the  embryo)  is  made  up  of  two  layers,  an  outer  fibrous 
layer  and  an  inner  layer  of  osteoblastic  cells.     In  this  latter  layer  med- 
ullary spaces   develop,  and  in 
them  the  osteoblasts   from  an 
active  formation  of   cells   and 
growth  of  vessels.     In  addition 
to  the   periosteal  or  perichon- 
dria! bone  formation  we  recog- 
^0J,     nise  an  endochondrial  bone  for- 
mation in  the  cartilage  of  em- 
bryonic bone  ;   this  takes  place 

Fig.  342.-Periosteal  formation  of  bone  from  osteo-      especially  in  the  grOWtll  of   the 
bli^ts  a ;  6,  newly  formed   bone;   c,  old  bone,      l^ng    boneS    at    the    epiphyseal 

junction.  Medullary  cavities 
develop  here  also,  and  a  portion  of  the  medullary  cells  change  into 
osteoblasts.  Opinion  differs  as  regards  the  importance  of  the  car- 
tilage cells  in  the  endochondrial  formation  of  bone,  Yirchow  and  oth- 
ers believing  that  the  cartilage  cells  change  into  medullary  cells  and 
osteoblasts,  while  Gegenbaur  and  Strelzoff  maintain  that  the  cartilage 
cells,  as  such,  perish,  and  take  no  part  in  the  formation  of  bone.  The 
latter  authorities  hold  the  view  that  the  osteoblasts  are  always  derived 
from  the  marrow  or  the  osteoblastic  layer  of  the  periosteum.  Maas's 
view  that  the  colourless  blood-corpuscles  are  capable  of  forming  the  cal- 
lus seems  to  me  untenable. 

The  transformation  of  the  osteoblasts  into  bone  tissue  is  brought 
about  by  a  change  of  the  greater  part  of  the  protoplasmic  material  into 
a  tissue  which  appears  homogeneous,  but  is  really  made  up  of  fine  fibrils, 
which,  after  taking  up  bone  salts,  forms  a  lamellated  ground  substance. 
Here  and  there  cells  persist  as  bone  cells,  which  are  enclosed  by  the 
newly  formed  bone  in  serrated  cavities,  having  fine  processes  radiating 
from  them.  These  are  the  so-called  bone-corpuscles.  Meyer  and  the 
mathematician  Cullmann  were  the  first  to  show  that  the  bony  structure 
and  trabecnlfe  are  arranged  according  to  mechanical  laws. 

Interstitial  Growth  of  Bone. — In  addition  to  this  appositional  growth 
of  bone  from  the  periosteum  and  medulla,  Oilier,  Yirchow,  and  others 
have  called  attention  to  the  occurrence  of  an  interstitial  growth — i,  e., 
an  expansion  of  the  bone  substance  already  formed.  This  was  dem- 
onstrated by  driving  pegs  and  boring  holes  into  growing  bone. 

Artificially  Increased  Growth  of  Bone. — Under  such  pathological  con- 
ditions as  necrosis,  chronic  inflammatory  processes,  compound  fractures, 


§  101.] 


FRACTURES. 


583 


chronic  joint  inflammations,  etc.,  as  a  result  of  irritation  of  the  epipli- 
yses,  an  increased  oTowth  of  bone  is  observed,  especially  in  the  long 
axis.  The  longitudinal  growth  can  be  artificially  increased  and  short- 
ening compensated  for  by  driving  ivory  pegs  into  the  bone,  or  tying 
oif  the  extremity  with  an  elastic  tournicpiet,  or  by  other  forms  of  irrita- 
tion acting  upon  the  diaj)hysis  in  the  neighbourhood  of  the  epiphysis, 
from  which  the  effects  are  transmitted  to  the  epiphyseal  cartilage 
(Oilier,  Langenbeck,  etc.).  In  the  case  of  a  compound  fracture  which 
healed  slowly  with  suppuration,  I  saw  a  shortening  of  eight  centimetres 
in  the  beginning  changed  to  three  centimetres  in  the  course  of  about 
one  to  one  and  a  half  year  as  a  result  of  an  abnormal  stimulation  of  the 
growth.  Sometimes,  even  in  subcutaneous  fractures,  the  shortening 
whicli  may  exist  at  first  disappears  after  a  year  or  two  by  augmented 
longitudinal  growth. 

Absorption  of  Bone  Substance. — Simultaneously  with  the  new  forma- 
tion of  bone  there  is  constantly  taking  place,  on  both  the  outer  and  inner 
surface  of  the  bone,  an  absorption  of  bone  substance  which  is  brought 
about  by  special  cells  called  osteoclasts  (Kolliker).  These  osteoclasts 
(Fig.  343)  usually 
have  the  appear- 
ance of  polynucle- 
ated  giant  cells, 
and,  according  to 
Kolliker,  are  de- 
rivatives of  the  os- 
teoblasts; butWeg- 
ner  maintains  that 
they  are  formed 
by  proliferation  of 
adventitia  cells, 
and  Recklinghausen,  that  they  originate  from  white  blood-corpuscles. 
According  to  Pommer,  the  cells  of  the  adventitia  of  the  blood-vessels, 
the  endothelial  cells  of  the  perivascular  lymph  spaces,  and  of  the 
Haversian  blood-vessels  themselves — in  short,  the  protoplasm  of  all 
the  cells  lying  near  the  bone  substance — are  capable,  under  certain 
conditions,  of  taking  on  osteoclastic  functions.  Pommer  states  that 
the  subsequent  history  of  the  osteoclasts,  as  well  as  their  derivation, 
varies,  and  that  osteoblasts  or  other  cells  may  be  made  from  them. 
He  ascribes  the  cause  of  the  production  of  the  osteoclasts  to  the  in- 
crease in  the  local  blood  pressure.  The  action  of  the  osteoclasts  is 
entirely  local,  the  bone  disappearing  in  the  form  of  small  pits  or 
lacunae  (Howship's  lacunae,  lacunar  bone  resorption.  Fig.  343).     The 


<^^<S^^ 


Fig.  343. — Lacunar  absorption  of  bone  by  osteoclasts  (0),  which  lie 
in  the  llowship's  lacunag. 


250. 


584:  INJURIES  AND  SURGICAL  DISEASES  OF   BONE. 

osteoclasts  probably  fonn  carbonic  acid,  by  which  the  lime  salts  are 
dissolved,  and  the  rest  of  the  ground  substance  is  assimilated  by  the 
osteoclasts  or  absorbed  by  the  blood  or  lymph  current. 

The  Ossification  of  the  Callus. — The  ossification  of  the  callus  takes 
place  in  precisely  the  same  way  as  in  the  development  of  bone.     The 
germinal  tissue  either  ossifies  as  such,  or  there  is  first  a  production  of 
hyaline  or  fibrous  cartilage.     In  the  deepest  layers  of  the  periosteal 
germinal  tissue,  and  hence  close  to  the  bone,  at  a  little  distance  from 
the  broken   ends    and   in   the   neighbourhood  of   the   normal   intact 
periosteum,  there  appear  by  the  third  or  fourth  day  small  collections 
of  bone-like,  "  osteoid "  tissue.     A  network  of  bony  trabeculse,  with 
enclosed   medullary  spaces,  gradually  develops.     During    the   second 
week  the  formation  of  the  periosteal  callus  is  so  far  advanced  that 
it  consists  of  a  great  number  of  osteoid  and  osteal  trabeculae — in  other 
words,  the  two  fragments  are  bound  together  by  a  young  osteophyte 
made  of  wide-meshed  bone  tissue.     At  the  end  of  the  third  week  (Fig. 
341)  the  periosteal  callus  usually  consists  of  fairly  firm,  spongy  bone. 
Simultaneously  with  the  formation  of  the  periosteal  callus  the  internal 
(myelogenic)  callus  develops  in  the  medulla  of  the  bone  in  the  same 
way.      On    the    inner    surface   of  the    cortex   a   tral)ecular  system   of 
osteoid  tissue  is  formed,  which  gradually  changes  into  true  bone  by 
the   deposition  of  bone  salts.      The  size  of  the  medullary  callus  va- 
ries greatly,  oftentimes  filling  the  entire  medullary  cavity,  while  in 
other  instances  it  may  only  develop  to  a  slight  extent.     In  the  me- 
dullary callus  also,  particularly  in  the  neighbourhood  of  the  point  of 
fracture,  hyaline  and  fibrous  cartilage  is  found,  though  not   so   con- 
stantly nor  in  so  large   amounts   as   in   the   periosteal   callus.      The 
so-called  intermediary  portion  of  the  callus,  which    lies   between  the 
broken  ends,  develops,  as  we  remarked  before,  principally  from  the 
periosteum. 

Retrogressive  Metamorphosis  of  the  Callus. — At  the  outset  the  callus 
is  made  up  of  spongy  bone  rich  in  marrow.  Tliis  so-called  provisional 
callus  is  then  transformed  into  the  permanent  bone  cicatrix  by  be- 
coming more  compact,  decreasing  in  circumference,  and  becoming 
smooth  on  its  surface.  This  involution  of  the  callus  may  reach  such 
completeness  that  the  bone  cicatrix  is  later  on  scarcely  visible.  If  the 
medullary  cavity  was  closed  by  the  medullary  callus  it  may  again  be- 
come free  by  absorption  of  bone.  Wherever  the  bone  substance  formed 
in  the  ossification  of  the  callus  is  not  functionally  necessary  it  is  ab- 
sorbed ;  while,  on  the  other  hand,  apposition  of  bone  substance  takes 
place  in  those  parts  of  the  callus  where  they  are  necessary  for  the 
firmness  of  the  bone  cicatrix.     In  this  way  the  structure  of  the  bone 


J5  101.] 


FRACTURES. 


585 


at  tlic  point  of  fracture  is  regenerated  as  completely  as  possible  and  as 
the  laws  of  statics  demand. 

Billroth,  Volkmann,  Oilier,  I'ruiis  and  others  have  been  instru- 
mental in  elucidating  the  subject  of  the  formation  of  the  callus,  but 
the  real  founder  of  the  experimental  study  of  callus  formation  is  Du- 
hamel  (ITiU),  who  showed  by  his  classical  investigations  that  the  callus 
is  not  produced  by  any  particular  fluid  of  the  body,  but  by  a  formation 
of  bone  from  the  periosteum  and  marrow. 

The  size  and  circumference  of  a  callus  varies  greatly,  according  to 
the  condition  and  position  of  the  broken  pieces,  the  location  of  the 
fracture,  and  the  size  of  the^bone.  Constitutional  conditions  also  exert 
an  influence.  The  strongest  callus,  as  a  general  thing,  develops  in 
fractures  through  the  diaphysis  of  the  long  bones,  which  heal  with  dis- 
placement, especially  if  the  fracture  has  been  com- 
pound. Considerable  disturbance  of  function 
may  be  produced  by  fractures  like  these  which 
heal  in  a  position  of  deformity  with  such  a  callus 
luxurians,  as  it  is  called  (Fig.  344).  The  callus  is 
generally  slight  in  flat  bones  like  the  scapula  or 
those  of  the  pelvis.  After  fractures  of  two  par- 
allel bones  which  lie  next  one  another,  as  is  the 
case  in  the  forearm,  it  is  possible  for  a  synostosis 
of  the  two  bones  to  occur.  After  fractures  in 
the  neighbourhood  of  joints  the  callus  sometimes 
extends  in  the  form  of  processes  into  the  capsule 
of  the  joint,  or  bridges  of  callus  develop,  extend- 
ing from  the  articular  end  of  one  bone  to  that  of 
the  other,  and  producing  anchylosis  of  the  joint. 
Occasionally  ti-ue  tumours  (callus  tumours)  form 
from  the  callus  at  the  point  of  fracture  ;  these  are 
sometimes  benign  osteomata,  or  enchondromata, 
and  sometimes  malignant  periosteal  or  myelogenic 
sarcomata  (Hal)eren). 

EflEect  of  Division  of  the  Nerves  upon  the  Callus  Formation. — W, 
Kusmin,  experimenting  upon  the  posterior  extremities  of  rabbits,  has 
studied  the  eflect  on  the  callus  of  dividing  the  nerves,  and  he  observed 
that  after  nerve  division  the  callus  is  larger  and  stronger  in  all  its 
stages  than  calluses  made  without  neurotomy,  and  the  deposit  of  lime 
salts  and  ossification  takes  place  at  an  earlier  period  and  more  exten- 
sively than  is  the  case  under  normal  conditions. 

Behaviour  of  Bone  Splinters. — ^It  is  of  special  interest  to  note  what 
happens  to  small  fragments  of  bone.     Those  which  remain  attached 


Fig.  344. — Fracture  healed 
with  deformity  (callus 
lu.xuriaus). 


586  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

to  the  periosteum  or  bone  heal  in  place  the  most  readily.  Smaller 
splinters  are  occasionally  absorbed.  If  bone  fi-agments  do  not  become 
united  to  the  rest  of  the  bone,  if  they  die  and  remain  near  the  point  of 
fracture,  consolidation  of  the  fracture  may,  in  the  case  of  large' frag- 
ments, be  very  much  delayed,  or  even  entirely  prevented,  unless  the 
dead  portion  of  bone — the  sequestrum,  as  it  is  called — is  removed  (see 
§  106,  JS^ecrosis  of  Bone).  But  it  has  been  frequently  noted,  and  even 
proved  experimentally  by  Oilier,  Bergmann,  and  others,  that  fragments 
which  have  been  completely  separated  from  the  bone  may  heal  in  place 
perfectly  in  the  case  of  subcutaneous  fractures  and  of  compound  frac- 
tures in  which  the  wound  heals  aseptically. 

Transplantation  of  Pieces  of  Bone  into  Defects  in  Bone. — The  many 
experiments  with  transplantation  of  portions  of  bone  into  defects  in 
bone  have  an  important  bearing  upon  the  subject  of  the  behaviour  of 
fragments  of  bone  which  have  been  entirely  separated  from  the  bone 
and  periosteum.  All  the  experiments  of  Oilier,  Bergmann,  and  others 
show  that  transplanted  portions  of  bone  with  or  without  periosteum 
heal  in  place  if  the  wound  runs  an  aseptic  course  and  if  no  suppuration 
takes  place.  Bergmann  and  Jakimowitsch  performed  twelve  experi- 
ments, in  ten  of  which  portions  of  bone  twenty  millimetres  long  with 
and  without  periosteum  and  marrow  were  successfully  transplanted  ; 
suppuration  occurred  twice,  and  in  both  instances  the  transplanted 
pieces  of  bone  failed  to  unite.  Jakimowitsch  succeeded  in  healing  a 
portion  of  a  rabbit's  phalanx  into  the  skull  of  a  dog.  As  a  general 
thing,  a  loss  of  bone  substance,  particularly  in  the  skull,  should  be  re- 
paired by  the  implantation  of  a  pedunculated  flap  consisting  of  bone, 
periosteum,  and  soft  parts.  On  the  skull  the  pedunculated  skin-perios- 
teum-bone flap  is  taken  from  the  vicinity  of  the  defect,  the  surface  of  the 
bone  being  chiselled  through,  leaving  the  inner  tablet  intact.  Nussbaum 
was  the  first  to  successfully  repair  loss  of  bone  substance  by  peduncu- 
lated periosteum-bone  flaps,  which  remained  connected  to  the  periosteum 
by  a  periosteal  bridge  at  one  end  of  the  fragment. 

MacEwen  successfully  repaired  a  loss  of  bone  substance  11*4  centi- 
metres long  in  the  diaphysis  of  the  humerus  by  transplantation  of  small 
pieces  of  bone  about  0*3  to  0-5  centimetre  in  diameter.  The  pieces  of 
bone,  including  periosteum  and  marrow,  were  obtained  from  osteoto- 
mies for  rhachitic  curvatures  in  small  children.  Oilier  has  successfully 
repaired  losses  of  bone  substance  by  the  transplantation  of  small  hollow 
bones,  such  as  the  first  phalanx  of  the  great  toe.  If  the  transplanta- 
tion of  bone  is  to  succeed,  the  strictest  asepsis  must  be  employed  to 
prevent  suppuration,  the  extremity  must  be  carefully  immobilised,  and 
the  transplanted  material,  including,  if  possible,  the  medulla  and  perios- 


§101.]  FRACTURES.  5S7 

tenm,  should  be  taken  while  it  is  in  process  of  vigorous  growth,  and 
consequently  from  young  subjects  or  newborn  children.  Gluck  has 
repaired  losses  of  bone  substance  by  pieces  of  ivory  (see  §  43 j*  but,  as 
Bergniann  found  in  one  instance,  the  cure  was  only  temporary,  and  he 
was  obliged  to  remove  the  ivory  peg  on  account  of  the  pain  and  con- 
tinued uselessness  of  the  hand.  !Senn  and  others  have  successfully 
employed  decalcified  bone.  In  ten  cases  in  which  he  had  good  results 
with  pieces  of  decalcified  bone  Le  Dentu  proceeded  as  follows :  He 
freed  the  bone  to  be  used,  which  was  generally  the  femur  or  tibia  of 
an  ox,  from  periosteum  and  medulla,  decalcified  it  by  immersion  for 
eight  days  in  a  sixteen-per-cent.  solution  of  hydrochloric  acid;  he  then 
washed  the  pieces  of  bone,  placed  them  for  twenty-four  hours  in  a 
solution  of  bichloride  of  mercury,  and  stored  them  in  iodoform  ether. 
These  implanted  decalcified  pieces  of  bone,  placed  like  an  internal  splint 
inside  the  bone,  are  eventually  completely  absorbed,  but  they  atimulate 
the  formation  of  bone.  Dead  pieces  of  bone  which  have  not  been  de- 
calcified and  are  below  a  certain  size,  as  proved  by  the  experiments  of 
Ochotin,  can  be  made  to  heal  in  place.  The  dead  pieces  of  bone,  like 
any  foreign  body,  are  first  surrounded  by  young  connective  tissue,  and 
are  then  permanently  enclosed  by  newly  formed  bone  tissue.  Vigor- 
ous processes  of  absorption  take  place  within  the  encapsulated  dead 
tissue,  by  which  small  pieces  of  bone  may  be  entirely  absorbed.  The 
dead  piece  of  bone,  as  Bergmann  has  correctly  stated,  is  either  encap- 
sulated by  bone  or  its  place  is  taken  by  living  bone  tissue.  If  a  large 
dead  piece  of  bone  is  made  use  of  for  the  functions  of  motion  or  sup- 
port, the  implanted  material  does  not  usually  heal  in  place,  and  inflam- 
matory (carious)  processes  take  place  in  the  adjoining  living  bone 
(Bergmann). 

Repair  of  Fractures  of  Cartilage.— The  process  of  repair  in  fractures 
of  cartilage,  such  as  the  ossifying  costal  cartilages  or  laryngeal  carti- 
lages which  are  covered  with  perichondrium,  is  mainly  carried  on  by 
the  perichondrium,  and  a  fibrous  cartilage  is  formed,  which  then  gradu- 
ally ossifies.  Eegressive  changes  usually  take  place  at  the  broken  ends, 
and  the  cartilage  undergoes  fatty  degeneration,  but  at  a  distance  a  little 
further  removed  from  the  broken  ends  of  the  cartilac^e  there  occurs  a 
vigorous  proliferation  of  cartilage  cells  and  a  formation  of  new  carti- 
lage tissue  (Tizzoni.  and  others).  In  cases  of  interruption  of  continu- 
ity and  loss  of  substance  in  the  cartilage  of  joints  which  is  not  pro- 
vided with  perichondrium,  a  fibrous  connective-tissue  cicatrix  ordinarily 
develops,  which  Tizzoni  states  is  capable  in  time  of  changing  into 
hyaline  cartilage  tissue.  Portions  of  cartilage  which  have  been  com- 
pletely broken  off  do  not  regain  their  attachments,  and  either  become 


588  INJURIES   AND   SURGICAL   DISEASES  OF   BONE. 

free  bodies  in  the  joint  or  are  encapsulated  by  new  connective  tissue 
formed  from  the  inner  surface  of  the  capsule. 

The  Time  required  for  Fractures  to  HeaL — The  time  wliich  is  re- 
quired for  the  callus  formation  to  reach  completion  and  render  the 
affected  bone  again  capable  of  performing  its  function,  depends  upon 
the  size  of  the  bone  which  is  involved,  the  nature  of  the  fracture,  and 
not  infrequently  also  upon  constitutional  conditions.  A  simple  subcu- 
taneous fracture,  as  a  general  thing,  heals  more  rapidly  than  a  com- 
minuted or  a  compound  fracture  with  considerable  injury  to  soft 
parts.  In  childhood,  healing  takes  place  more  rapidly  than  in  adult 
life.  The  healing  of  a  fracture  may  be  prolonged  by  constitutional 
anomalies,  such  as  the  occurrence  at  the  same  time  of  severe  acute 
constitutional  infectious  diseases,  or  by  syphilis,  scurvy,  diabetes  mel- 
litus,  and  not  infrequently  by  pregnancy.  Gurlt  has  given  the  follow- 
ing periods  as  those  required  for  the  healing  of  simple  subcutaneous 
fractures :  A  broken  phalanx  needs  about  two  weeks,  the  metacarpus, 
metatarsus  and  ribs  three,  the  clavicle  four,  the  forearm  five,  the  hu- 
merus and  fibula  six,  the  neck  of  the  humerus  and  the  tibia  seven, 
both  bones  of  the  leg  eight,  the  femur  ten,  and  the  neck  of  the  femur 
twelve  weeks  before  consolidation  is  complete. 

Condition  of  the  Soft  Parts  and  Joints  after  Healing  of  a  Fracture. — 
After  consolidation  of  a  fracture  the  full  usefulness  of  the  joint  is  not 
immediately  restored,  and  the  muscles  very  frequently  have  become 
atrophic  as  a  result  of  their  long  inactivity.  From  long-continued 
immobilisation  or  too  tight  dressings  this  atrophy  of  the  muscles,  par- 
ticularly in  anaemic  individuals,  may  give  rise  to  the  isch^emic  paraly- 
ses and  contractures  mentioned  on  page  549.  Sometimes  the  functions 
of  the  muscles  are  disturbed  by  cicatricial  shrinkage  as  a  direct  result 
of  the  injury,  or  by  their  insertion  having  been  torn  away,  or  by 
paralysis  in  consequence  of  a  complicating  injury  to  the  nerves,  or 
from  compression  of  the  nerves,  for  instance,  by  the  callus.  The  skin 
very  often  exhibits  slight  disturbances  of  nutrition ;  it  is  dry  and 
rough,  and  the  epidermis  comes  off  in  scales.  Very  frequently  there 
are  varying  degrees  of  tedema  of  the  skin  and  subcutaneous  soft  parts. 
The  rest  which  the  healing  of  a  fracture  enjoins  also  exerts  a  disad- 
vantageous influence  upon  the  condition  of  the  joints  (Menzel,  Eeyher). 
In  consequence  of  the  shrinkage  of  the  capsule  of  joints  immobilised 
by  the  fracture  dressing,  the  joints  are  more  or  less  stiff  after  the 
splint  is  removed,  and  sometimes  inflammatory  effusions  occur.  Ordi- 
narily, with  the  increasing  use  of  the  joint  and  under  proper  treatment 
(by  massage  and  passive  motion)  these  disturbances  very  soon  disap- 
pear.    In  other  cases  joint  inflammations  have  their  foundation  in  a 


§101.] 


FRACTURES. 


589 


direct  injury  of  the  joint,  and  under  these  circumstances  it  is  possible 
for  ])ernianent  joint  disturbances,  inflannnation  giving  rise  to  deformity, 
anchylosis,  etc.,  to  occur  (see  Diseases  of  rioints). 

Course  of  the  Epiphyseal  Separations. — The  separations  of  the  epiph- 
yses run  essentially  the  same  course  as  fractures  of  the  bone.  We 
still  lack  precise  anatomical  knowledge  upon  the  phenomena  of  their 
healing.  Great  interest  attaches  to  the  question  of  how  much  dis- 
turbance after  epiphyseal  sejmrations  has  been  observed  in  the  growth 
of  the  affected  bone  on  account  of  ossilication  of  the  epiphyseal  carti- 
lage. Unfortunately,  only  a  few  observations  have  been  recorded  on 
this  subject.  BruTis's  statistics  show 
that  a  consequent  arrest  of  devel- 
opment only  occurs  in  rare  and  ex- 
ceptional instances  to  any  marked 
degree.  Vogt  has  recorded  obser- 
vations of  this  kind.  In  Fig.  345  is 
represented  a  shortening  of  the 
humerus  amounting  to  twelve  and 
one  half  centimetres  in  a  thirty- 
year-old  woman  which  was  proba- 
h]y  the  result  of  a  traumatic  separa- 
tion of  the  epiphysis  sustained  in 
childhood,  with  subsequent  anchy- 
losis of  the  shoulder  joint.  Short- 
ening develops  especially  when  the 
diaphysis  and  epiphysis  are  driven 
into  one  another  and  heal  together 
in  this  position. 

Disturbances  during  the  Healing 
of  Fracturea— The  most  important  disturbances  which  may  arise  while 
a  fracture  is  healing  are  briefly  as  follows : 

1.  Shock.     See  §  63. 

2.  Delirium  Tremens.     See  §  64. 

3.  Infectious  Diseases  of  Wounds.  See  §§  66-75. — These  are  par- 
ticularly liable  to  occur  in  the  case  of  compound  fractures  which  have 
not  been  treated  antiseptically. 

4.  Gangrene.  See  §  100. — This  may  be  caused  by  severe  injury  of 
the  soft  parts,  by  injury  to  the  larger  vessels,  by  pressure  of  the  frag- 
ments upon  the  main  artery,  by  improper  treatment,  such  as  too  tight 
dressings,  etc. 

5.  Necrosis  of  the  Ends  of  the  Fragments. — This  is  especially  apt 
to  occur  in  compound  fractures  when  the  broken  ends  lie  in  the  wound 


Fig.  345. — Impeded  growth  of  the  right  liu- 
merus,  prolmhly  resulting  from  a  trau- 
matic separation  of  the  epiphysis  (Bryantj. 


590  INJURIES  AND  SURGICAL   DISEASES  OP   BONE. 

stripped  of  their  periosteum,  or  when  they  are  badly  crushed  or  splin- 
tered into  several  fragments,  or  when  the  periosteum  and  medulla 
are  to  a  great  extent  destroyed  by  suj)puration  and  sloughing.  The 
dead  bone — or  sequestrum,  as  it  is  called — is  then  separated  from  the 
living  bone  by  a  demarcating  suppuration  (see  §  106,  Necrosis  of  Bone). 

6.  Fat  Eviholl. — Probably  in  every  fracture,  as  a  result  of  the 
laceration  of  the  bone  marrow  and  subcutaneous  adipose  tissue,  fluid 
fat  gains  access  to  the  blood  and  lymph  vessels  which  are  opened  at 
the  point  of  fracture.  "Wherever  the  lumen  of  the  vessels  is  too  small 
for  the  passage  of  the  fat  drops  circulating  in  the  l)lood  at  this  point, 
these  drops  lodge  and  occlude  the  vessel.  Fat  emboli  of  this  kind 
following  fractures  are  observed  ])articularly  in  the  pulmonary  capilla- 
ries, and  they  also  frequently  occur  in  the  smallest  vessels  of  the  brain, 
kidneys,  liver,  intestinal  villi,  etc.  As  long  as  the  fat  emboli  are  scat- 
tered and  not  extensive  their  occurrence  is  entirely  unimportant ;  the 
fat  produces  no  symptoms  worth  mentioning  of  either  a  local  or  consti- 
tutional nature,  beyond  causing  a  temporary  occlusionof  the  lumen  of 
the  vessel  in  question.  But  sometimes  the  fat  emboli  in  the  lungs  or 
brain  are  so  numerous  and  so  extensive  as  to  cause  death,  not  only  in 
those  weakened  by  age,  but  now  and  then  in  those  who  are  in  the 
prime  of  life.  Death  is  due  to  a  pronounced  accumulation  of  fat  in 
the  capillaries  of  either  the  lungs  or  the  brain.  Scriba  has  performed 
experiments  to  determine  the  manner  in  which  fat  emboli  act,  and  he 
maintains  that  death  is  mainly  the  result  of  their  lodgement  in  the 
brain.  As  a  rule,  death  occurs  about  three  to  four  days  after  the  frac- 
ture, and  in  such  cases  there  is  a  continual  accumulation  of  fat,  during 
several  days,  in  the  capillaries  of  the  lungs  and  brain,  which  finally 
causes  a  more  or  less  sudden  functional  incapacity  of  these  organs.  It 
is  comparatively  seldom  that  death  is  the  result  of  fat  emboli  alone ; 
there  are  generally  other  complications. 

Y.  EinhoUsm  of  the  Puhnonari/  Artery  following  Thromljosis  of 
the  Larger  Yeins  at  the  Point  of  Fracture. — This  serious  complication 
may  occur  particularly  after  thrombosis  of  the  deep  veins  in  fractures 
of  the  lower  extremity.  The  thrombus  in  the  vein  may  break  loose 
either  while  the  patient  is  lying  quietly  in  bed,  or  because  of  some 
movement  of  the  body,  from  massage,  or  from  a  change  of  the  dress- 
ing, and  death  may  follow  within  a  few  seconds  from  embolism  of  the 
pulmonary  artery.  K«3nig  observed  death  from  embolism  of  the  pul- 
monary artery  on  the  eighteenth  day  after  a  subcutaneous  fracture  of 
the  leg  in  a  strong  man  thirty  years  of  age.  When  the  patient  was 
laid  upon  the  operating  table  preparatoi-y  to  changing  the  dressings, 
he  was  suddenly  seized  with  cramps  and  opisthotonus,  the  pupils  be- 


55  lot. 


FRACTURES. 


591 


came  dilated,  and  he  died  in  a  few  moments.  The  autopsy  revealed  a 
large  clot  lodged  in  the  pulmonary  artery,  and  it  was  only  with  diffi- 
culty that  the  point  was  found  in  the  vena  tibialis  antica  where  the 
thrombus  had  originated. 

8.  Ila'niori'hage. — In  compound  and  subcutaneous  fractures  ha3mor- 
rhage  may  occur  as  a  result  of  the  violence  which  has  been  brought  to 
bear  u])on  the  part,  or  it  may  be  produced  by  pointed  fragments, 
splinters  of  bone,  etc.  (see  §§  87-89). 

9.  Constitutional  anomalies  play  an  important  part  in  respect  to 
the  prognosis  in  the  case  of  any  fracture.  A  fracture  sustained  by  a 
very  old  person  and  entailing  a  long  confinement  in  bed  is  a  serious 
accident,  for  the  reason  that  life  may  readily  become  endangered  by 
hypostatic  pneumonia. 

10.  Delay  in  the  formation  of  the  callus  is  particularly  apt  to 
occur  when  constitutional  anomalies  exist,  or  in  acute  and  chronic 
infectious  diseases  (typhoid  fever,  syphilis,  scurvy),  in  diabetes  mellitus, 
in  diseases  of  the  peripheral 

nerves  and  central  nervous  ,        \ 

system,  such  as  progressive 
paralysis,  or  during  preg- 
nancy, etc. 

1 1 .  Pse  uda  rth  rosis.  — 
If  bony  union  does  not  take 
place  between  the  frag- 
ments, the  resulting  condi- 
tion is  called  a  pseudarthro- 
sis — i.  e.,  a  false  joint  (see 
Fig.  316).  In  a  case  of 
pseudarthrosis,  the  frag- 
ments are  either  entirely 
free  from  connection  with  one  another,  or  they  are  joined  together  by 
a  connective-tissue  or  cartilaginous  intervening  sul>stance  of  varying 
strength.  In  rare  instances  a  kind  of  true  joint  is  observed  at  the 
point  of  fracture — i.  e.,  the  ends  of  the  fragments  are  covered  with  a 
layer  of  h^'aline  cartilage,  and  a  shallow  cavity  is  hollowed  out  of  one 
fragment,  while  the  other  is  rounded  to  fit  it ;  the  periosteum  and 
neio-hbourino;  connective  tissue  surrounds  and  encloses  the  broken 
pieces  in  the  form  of  a  capsule,  and  in  some  cases  there  will  be  found 
in  the  joint-like  cavity  a  fluid  which  resembles  synovia.  In  pseudar- 
throses  such  as  this,  even  synovial  villi  and  loose  bodies  have  been 
found,  the  latter  sometimes  in  great  numbers. 

Occurrence  of  Pseudarthrosis. — In  general,  pseudarthrosis  is  not  of 


Fig.  346. — Pseudarthrosis  of  the  humerus  twelve  years 
old  in  a  fifty-three-old  man. 


592  INJURIES  AND  SURGICAL   DISEASES  OP  BONE. 

common  occurrence.  Karmilow  states  that  a  pseudartlirosis  takes 
place  once  in  about  three  hundred  or  four  hundred  fractures.  The 
pseudarthroses  following  fracture  of  the  neck  of  the  femur  and  frac- 
ture of  the  patella  are  the  most  frequent.  Bruns's  statistics  seem  to 
show  that  childhood  and  old  age  predispose  less  to  pseudartlirosis  than 
middle  life. 

Causes  of  Pseudartlirosis. — The  causes  of  pseudartlirosis  are  usually 
local  in  their  nature,  being  principally  those  which  prevent  exact  coap- 
tation of  the  wounded  bone  surfaces.  A  pseudarthrosis  may  result,  for 
example,'  from  a  diastasis  of  the  fragments,  such  as  often  occurs  after 
transverse  fracture  of  the  patella  or  after  loss  of  a  large  portion  of  a 
bone,  owing  to  its  becoming  extensively  crushed  ;  or  the  affection  may 
result  from  displacement  of  the  fragments,  or  from  interposition  of 
muscles,  tendons,  fascia,  foreign  bodies  (bullets),  pieces  of  dead  bone, 
etc.,  between  the  fractured  surfaces.  In  other  cases — for  instance, 
after  intracapsular  fractures  of  the  neck  of  the  femur,  or  intracapsular 
fractures  of  the  neck  of  the  humerus— the  pseudartlirosis  is  caused  by 
the  insufljcient  nourishment  of  one  of  the  fragments.  Pseudartlirosis 
may  also  originate"  in  consequence  of  insufficient  coaptation  of  the  frac- 
tured surfaces  due  to  defective  dressings,  particularly  if  the  fracture  is 
oblique;  under  these  conditions  the  fragments  are  permitted  to  move 
and  become  separated.  An  influence  is  sometimes  exerted  in  this  di- 
rection by  a  paralysis  which  may  exist  at  the  time  of  the  fracture,  or 
by  too  little  inflammatory  reaction  in  consequence,  for  example,  of  the 
wound  healing  aseptically  in  the  case  of  compound  fractures.  ^  Consti- 
tutional disturbances,  especially  the  general  weak  condition  which  fol- 
lows severe  febrile  diseases,  loss  of  blood,  prolonged  lactation,  preg- 
nancy, etc.,  have  in  rare  instances  given  rise  to  pseudarthroses.  Under 
these  circumstances  it  has  also  happened  that  an  already  ossified  callus 
has  softened  and  been  completely  absorbed. 

The  degree  of  functional  disturbance  resulting  from  a  pseudar- 
throsis depends  mainly  upon  the  location  of  the  latter,  the  function  of 
the  bone  which  is  involved,  and  especially  upon  the  a'mount  of  motion 
possessed  by  the  false  joint.  In  a  pronounced  pseudarthrosis  of  a  long 
bone,  like  the  femur  or  humerus,  the  afl^ected  portion  of  the  limb  or 
the  entire  extremity  is  quite  useless,  unless  some  supporting  apparatus 
is  worn. 

Diagnosis  of  Fractures. — The  diagnosis  of  fractures  is  made  from  the 
above-described  symptoms.  In  order  to  make  out  the  latter,  a  system- 
atic and  careful  examination  of  the  injury  should  be  undertaken.  This 
examination  consists :  1.  In  a  thorough  inspection  of  the  injured  por- 
tion of  the  bod3',  noting,  for  example,  changes  in  its  shape  and  disturb- 


§  101.]  FRACTURES.  593 

ances  of  function.  2.  In  palpation  of  the  place  where  tlie  fracture  is 
presumed  to  be,  combined  with  passive  motion.  3.  In  an  exact  meas- 
urement of  the  length  of  the  injured  bone,  or,  rather,  the  extremity,  to 
determine  the  presence  and  amount  of  shortening.  Simple  inspection 
will  often  be  sufficient  for  the  immediate  recognition  of  a  fracture.  En- 
tirely apart  from  the  crepitation  and  abnormal  mobility,  the  character- 
istic linear  pain  obtained  by  palpation  of  the  line  of  fracture  will  fre- 
quently betray  the  existence  of  a  fracture.  In  order  to  palpate  the  line 
of  fracture  more  readily,  the  extravasation  at  the  point  of  fracture 
should,  when  practicable,  be  removed,  or  at  least  diminished  in  amount, 
by  gentle  massage.  The  corresponding  sound  portion  of  the  body  should 
always  be  compared  with  the  injured  part,  with  a  view  to  determining 
how  far  the  normal  position  of  the  constituent  parts  has  been  altered  by 
the  injury.  Xot  infrequently  we  have  to  make  the  examination  during 
narcosis  to  find  out  the  exact  nature  of  the  fracture,  especially  when  it 
is  compound.  In  all  cases  where  the  diagnosis  of  fracture  is  doubtful, 
the  injury  should  always  be  treated,  for  the  first  at  least,  according  to 
the  rules  which  govern  the  treatment  of  fractures. 

Percussion  and  Anscultation  of  Bones.— Lucke  and  Hueter  have  recom- 
mended percussion  and  auscultation  of  the  bone  as  an  aid  in  the  diagrnosis  of 
fractures,  particularly  when  it  is  desired  to  determine  the  presence  of  fissures 
in  the  skulJ,  which  can  be  I'ecoguised  by  the  pain  the  patient  feels  during  the 
percussion.  If  soft  parts  are  interposed  between  the  ends  of  the  fragments, 
Hueter  states  that  auscultation  (osteophony)  will  show  a  diminution  or  com- 
plete cessation  of  the  conduction  of  sound. 

The  Prognosis  of  Fractures. — The  prognosis  of  subcutaneous  fractures 
without  much  injury  of  the  surrounding  soft  parts  is,  in  general,  favour- 
able. Transverse  fractures  heal  more  rapidly  and  are  less  apt  to  cause 
lasting  deformity  than  oblique  fractures.  The  location  of  the  fracture 
is  an  exceedingly  important  matter  as  regards  the  prognosis.  The 
latter  is  more  favourable  in  fractures  of  the  extremities  than  in  those  of 
the  bones  of  the  skull,  trunk,  and  pelvis,  in  which  the  concomitant  in- 
juries of  neighbouring  organs  of  vital  importance,  such  as  the  brain, 
spinal  cord,  lungs,  heart,  bladder,  etc.,  may  readily  give  rise  to  very 
serious  disturbances  or  death.  In  other  cases  injury  to  a  neighbouring 
large  vessel  may  cause  fatal  haemorrhage,  or,  when  the  middle  meningeal 
artery  is  wounded,  cerebral  compression,  with  possibly  fatal  results. 

Fractures  of  the  lower  extremities  in  old  people,  necessitating  their 
confinement  to  bed  for  weeks,  are  always  to  be  looked  upon  as  severe 
injuries.  As  a  result  of  the  long-continued  dorsal  decubitus,  general 
disturbances  of  nutrition,  bronchitis,  and  hypostatic  processes  in  the 
lungs  readily  develop,  which  very  often  terminate  fatally.  This  fact 
88 


594  INJURIES   AND  SURGICAL  DISEASES  OF   BONE. 

is  of  therapeutic  importance,  as  it  teaches  ns  in  proper  cases  to  permit 
patients  with  fracture  of  the  neck  of  the  femur,  for  example,  to  get 
about  on  crutches  as  soon  as  possible. 

The  prognosis  of  fractures  involving  the  articular  ends  of  bones  of 
the  extremities  is  very  frequently  unfavourable,  particularly  as  regards 
restoration  of  the  functions  of  the  joint. 

The  character,  of  the  fracture  exerts  a  very  important  influence  upon 
the  prognosis  as  regards  the  preservation  of  the  patient's  life  and  the 
savino-  of  the  injured  limb,  as  well  as  its  complete  restitutio  ad  integrum. 
Compound  fractures,  in  particular,  are  always  to  be  looked  upon  as 
severe  injuries,  and  ones  which  threaten  both  the  limb  and  life  itself, 
but,  thanks  to  Lister's  antiseptic  method  of  treating  wounds,  we  are  no 
longer  powerless  to  combat  infectious-wound  diseases.  In  the  pre-anti- 
septic  times  the  mortality  of  compound  fractures  amounted  to  thirty- 
five  to  forty  per  cent.,  and  in  especially  infected  hospitals  even  to  sixty 
to  seventy  per  cent,  and  more.  Three  quarters  of  the  fatal  cases  were 
due  to  septicaemia  and  pysemia.  At  present  the  mortality  of  compound 
•fractures,  when  timely  and  proper  antiseptic  treatment  is  bestowed  upon 
the  wound,  is  extremely  small,  for  tlie  reason  that  we  have  learned  to 
prevent  infectious-wound  diseases.  During  four  years  and  a  half  Volk- 
mann  cured  seventy-five  compound  fractures  without  having  a  single 
death.  From  this  it  is  plain  that  the  prognosis  of  a  compound  frac- 
ture is,  in  general,  more  favourable  the  earlier  it  is  placed  under  the 
protection  of  antiseptic  treatment. 

Frequently  it  may  be  impossible  to  preserve  the  broken  limb,  so 
that  either  immediately  after  the  injury,  or  later,  amputation  of  the  ex- 
tremity must  be  undertaken. 

The  extent  to  which  the  prognosis  of  any  fracture,  subcutaneous  as 
well  as  compound,  may  be  affected  by  various  accidental  circumstances, 
has  been  described  on  pages  589-592. 

Treatment  of  Fractures. —The  first  aid  to  the  person  who  has  just 
sustained  a  fracture  often  falls  to  the  share  of  the  laity  who  happen  to 
be  present  at  the  accident.  Unfortunately,  their  assistance  fi-equently 
does  more  harm  than  good.  In  fractures  of  the  upper  extremity  the 
patient  usually  instinctively  places  the  broken  limb  in  a  proper  position. 
But  the  conditions  are  entirely  different  in  all  fractures  of  the  pelvis, 
vertebra3,  and  lower  extremity,  in  consequence  of  whicli  the  injured 
person  is  unable  to  walk.  Under  these  conditions  the  patient  must  be 
lifted  cautiously  after  securely  supporting  the  point  of  fracture.  If  an 
individual  who  has  received  an  injury  of  this  kind  has  to  be  transported 
to  his  home  or  to  a  hospital,  the  fractured  part  should  be  placed  in  the 
most  secure  position  possible,  a  suitable  temporary  dressing  applied  to 


^101.]  FRACTURES.  595 

prevent  unnecessary  pain  and  displacement  of  the  ends  of  the  frag- 
ments, as  well  as  serious  injuries,  such  as  perforation  of  the  skin  and 
severe  wounds  of  the  soft  parts,  particularly  of  the  vessels,  with  dan- 
gerous haemorrhage,  etc.  Great  care  should  be  used  in  removing  the 
patient's  clothes,  portions  of  the  latter — his  boots,  etc. — when  uecessary, 
being  slit  up  with  a  knife  or  scissors.  The  technique  of  applying  an 
impromptu  dressing,  the  various  splints,  the  arrangement  of  the  bed, 
the  position  of  the  patient,  etc.,  are  described  in  §§  52-55. 

The  proper  treatment  for  fractures,  particularly  those  which  are 
subcutaneous,  consists  in  correcting  the  deformity  as  soon  as  possible — 
i.  e.,  in  reposition  or  reduction  of  the  fragments,  and  in  retention  or 
fixation  of  the  broken  pieces  after  they  have  been  placed  in  apposition 
by  a  suitable  retentive  dressing  until  bony  union  is  complete. 

Reposition  of  the  Fragments. — The  reposition  or  reduction  of  the  dis- 
placed fragments  into  their  normal  position  is  usually  brought  about  by 
extension  (traction)  and  counter-extension  in  the  longitudinal  axis  of 
the  broken  bone.  The  extension  and  counter-extension  of  the  broken 
limb  are  usually  cautiously  performed  by  two  assistants,  while  the  sur- 
geon grasps  the  point  of  fracture  and  brings  the  fragments  into  their 
normal  position  (coaptation).  Manual  reposition  or  reduction  will  al- 
most always  be  sufficient.  If  great  force  has  to  be  used,  or  if  the  pain 
is  intense,  narcosis  may  have  to  be  employed.  Extension  apparatus, 
such  as  the  pulley  or  Schneider- Mennel's  frame,  which  were  at  one  time 
very  much  used,  have  become  antiquated.  The  reduction  of  many  frac- 
tures, such  as  those  of  the  bones  of  the  face  or  through  the  condyles  in 
the  immediate  neighbourhood  of  a  joint,  etc.,  can  be. accomplished  sim- 
ply by  direct  manipulation,  without  extension  and  counter-extension. 

Obstacles  to  Reduction. — Occasionally  various  obstacles  stand  in  the 
way  of  the  successful  reduction  of  a  fracture.  These  include  the  inter- 
position of  splinters  of  bone  or  of  soft  parts  between  the  fragments, 
impaction  of  the  broken  ends  in  fractures  of  the  articular  extremities 
of  bones,  and  the  impossibility  of  bringing  sufficient  power  to  bear  upon 
the  fragments.  Impaction  of  the  broken  ends,  such  as  may  occur  in 
fractures  of  the  neck  of  the  femur,  should  be  let  alone,  for  the  reason 
that  the  impaction  favours  consolidation  of  the  fracture. 

Application  of  Retentive  Dressings. — There  are  a  great  number  of 
splints  and  dressings  described  in  §§  53-55  for  holding  the  fragments 
in  their  normal  position  after  they  have  been  brought  into  apposition. 
The  ordinary  dressing  for  a  fracture  is  the  rapidly  hardening  retentive 
appliance  made  of  plaster  of  Paris  (page  216).  Extension  apparatus 
are  generally  used  for  fractures  of  the  thigh,  and  can  also  be  employed 
for  the  upper  extremity  (see  §  55,  page  229),  while  special  splints  are 


596  INJURIES  AND   SURGICAL    DISEASES  OF   BONE. 

recommended  for  many  fractures,  such  as  those  of  the  lower  end  of  the 
radius.  The  hardening  retentive  dressings  should  be  applied  as  soon 
as  possible,  and  it  very  often  happens  that  subcutaneous  fractures  will 
heal  under  a  single  dressing.  If  the  swelling  at  the  point  of  fracture 
is  considerable,  ice  can  be  applied  to  the  surface  for  several  days  with 
advantage,  and  then,  after  the  inflammatory  swelling  has  been  reduced, 
the  limb  can  be  placed  in  the  hardening  dressing.  Even  though  the 
swelling  is  marked  the  plaster-of-Paris  dressing  can  be  immediately  ap- 
plied, if  the  parts  are  first  carefully  padded  with  cotton.  In  such  cases 
the  hardening  dressing  has  an  antiphlogistic  effect  from  its  gentle  and 
even  pressure — i.  e.,  it  prevents  an  increase  in  the  swelling.  After  a 
certain  length  of  time  this  dressing  becomes  loose  and  does  not  suffi- 
ciently immobilise  the  point  of  fracture,  and  hence  it  must  be  taken  off 
and  replaced  by  a  new  one.  In  putting  on  the  hardening  dressing  great 
care  must  be  taken  not  to  apply  it  too  tightly.  Subsequently  the  fingers 
and  toes  should  be  carefully  watched,  and  if  they  swell  or  become  blu- 
ish-red or  oedematous,  if  pain  or  a  feeling  of  numbness  occur,  the  band- 
age has  been  applied  too  tightly  and  must  be  immediately  removed. 
Every  plaster-of-Paris  dressing,  whenever  it  is  possible,  should  be  again 
carefully  inspected  some  hours  afterwards  to  determine  whether  it  has 
not  been  applied  too  tightly.  Incurable  ischeemic  muscular  contractures 
may  readily  develop  within  a  few  hours  after  the  application  of  a  plas- 
ter-of-Paris dressing  which  is  too  tight  (see  page  549),  and  for  these  the 
attending  physician  can  be  held  legally  responsible. 

A  warning  should  be  given  against  the  too  prolonged  use  of  re- 
tentive dressings  and  the  rest  in  bed  which  this  entails,  because  of  the 
bad  effect  produced  upon  tlie  general  health,  the  atrophy  of  tlie  mus- 
cles, the  enforced  disuse  of  the  joints,  etc.  On  account  of  these  serious 
possibilities,  and  particularly  on  account  of  the  danger  of  hypostasis, 
old  people  with  fractures  of  the  lower  extremities  must  often  be  allowed 
to  leave  their  bed  and  go  about  on  crutches  with  a  suitable  splint,  and 
with  a  raised  sole  on  the  shoe  of  the  sound  leg.  Eecently  successful 
results  have  been  obtained  by  allowing  all  patients  with  fractures  to 
walk  about  with  suitable  splint  dressings,  and  by  avoiding,  for  the 
above-mentioned  reasons,  the  treatment  with  dressings  which  require 
a  long  confinement  to  bed.  Within  five  to  seven  days  the  patients  are 
allowed  to  move  around  on  crutches  in  a  proper  retentive  apparatus, 
such  as  a  Thomas  splint,  with  a  raised  sole  under  the  foot  of  the  sound 
side  (see  second  edition  Special  Surgery,  vol.  ii.  Fig.  723,  p.  623).  The 
results  are  very  satisfactory,  and  the  time  required  for  healing  to  be 
accomplished  is  shortened. 

Treatment  of  Subcutaneous  Fractures  involving  a  Joint. — In   sub- 


§  101.]  FRACTURES.  597 

cutaneous  fractures  involving  a  joint  special  care  must  be  taken  to  pre- 
vent the  development  of  anchylosis  or  a  partially  stiff  joint  (contrac- 
tures). This  is  best  accomplished  by  the  use  of  suitable  splints  or  a 
plaster-of-Paris  dressing,  which  should  be  frequently  changed — every 
five  to  eight  days,  for  example — and  reapplied  after  altering  the  posi- 
tion of  the  joint.  Massage  and  passive  motion  may  be  combined  with 
this — for  example,  at  every  change  of  dressing.  Extension  appliances 
are  also  very  useful,  and  may  be  em])loyed,  as  Bardenheuor  has  recently 
recommended,  even  for  fractures  of  the  upper  extremity  which  involve 
joints.  If  it  is  difficult  to  maintain  the  fragments  in  position  after  they 
have  been  reduced,  they  may  be  fastened  together  by  aseptic  steel  nails 
or  pins  (see  page  111). 

Treatment  of  Traumatic  Separation  of  the  Epiphysis. — For  securing 
bony  union  after  traumatic  separations  of  the  epiphyses,  the  fragments 
should  be  directly  united  by  long  aseptic  steel  nails  or  pins  (Trendelen- 
burg, Bruns,  etc.).  Helf  erich  has  recommended  long  steel  pins  attached 
to  a  removable  handle,  by  which  they  can  be  slowly  screwed  into  a 
bone ;  they  can  be  used  for  both  subcutaneous  and  compound  epiphy- 
seal separations. 

Direct  Fixation  of  the  Fragments  in  Subcutaneous  and  Open  (Com- 
pound) Fractures,  Suturing,  Nailing,  etc.— In  all  subcutaneous  or  com- 
pound fractures,  where  it  is  difficult  to  maintain  the  fragments  in 
proper  position,  the  wounded  bone  surfaces  can  be  held  in  contact  by 
directly  suturing  them  together,  by  driving  nails  into  them,  or  ivory 
pegs,  or  Helferich's  steel  pins,  or  by  placing  bone  or  ivory  pegs  in 
the  medullary  cavity,  as  described  in  §  34  (Union  of  Wounded  Bone 
Surfaces).  In  this  category  belong  Malgaigne's  hooks  for  fracture  of 
the  patella  and  Malgaigne's  pin  for  fracture  of  the  tibia — instruments 
which  are  scarcely  ever  used  at  present.  If  nails  are  to  be  used  to 
secure  fixation  of  the  bones,  long  four-cornered  steel  ones  should  be 
employed.  These  are  polished,  boiled  for  fifteen  minutes  in  a  one-per- 
cent, soda  solution,  heated  red-hot,  and  placed  in  a  ten-per-cent.  solution 
of  carbolic  acid  in  glycerine,  after  which  they  are  perfectly  sterile. 
After  the  bones  have  been  nailed  together  they  are  securely  immobilised. 
The  wounds  in  compound  fractures  are  not  sutured,  but  packed  with 
sterilised  gauze.  The  nails  are  removed  about  the  beginning  of  the 
fourth  week. 

The  Treatment  of  Open  (Compound)  Fractures. — The  treatment  of 
open  (compound)  fractures  has  been  totally  changed  by  the  antiseptic 
method  of  treating  wounds,  and  the  results  which  we  now  obtain  are 
very  satisfactory.  Typical  cases  of  compound  fracture  which  run  an 
aseptic  course  heal  without  pain  and  without  fever  ;  the  discharge  from 


598  INJURIES  AND   SURGICAL   DISEASES  OF   BONE. 

the  wound  is  slight,  and  we  are  certain  of  being  able  to  prevent  sup- 
puration. 

The  technique  of  the  antiseptic  treatment  of  the  wound  varies  with 
the  kind  of  case.  For  this  reason  we  distinguish  three  classes  of  cases : 
1.  The  perfectly  fresh  fractures  in  which  the  wound  is  the  result  of 
a  perforation  of  the  skin  by  a  fragment.  2.  The  ordinary  severe  cases 
of  compound  fracture.  3.  The  compound  fractures  which  are  not 
recent  and  have  already  become  infected. 

1.  Treatment  of  Fresh  Fractures  with  Transfixion  of  the  Skin  by  a  Frag- 
ment.— The  antiseptic  management  of  a  perfectly  fresh  fracture  com- 
plicated with  a  perforation  of  the  skin  by  a  fragment  is  as  follows : 
We  will  suppose  that  we  have  to  deal  with  a  fracture  accompanied  by 
only  a  small,  still  bleeding  cutaneous  M'ound,  similar  to  a  punctured 
wound  ;  that  the  case  comes  under  observation  immediately  or  within  a 
few  hours  after  the  reception  of  the  injury  ;  that  there  is  no  large  ex- 
travasation of  blood  present ;  that  the  bone  is  simply  broken,  and  not 
splintered  ;  and  that  no  infectious-wound  disease  can  be  made  out.  In 
such  cases  e^nlargement  of  the  wound  and  drainage  can  be  omitted. 
After  disinfection  of  the  wound  and  surrounding  parts,  as  described  in 
§  T)  and  §  32,  the  wound  is  covered  with  an  antiseptic  dressing,  such  as 
sterilised  gauze,  folded  together  into  several  layers,  and  cotton,  wool, 
or  pads  filled  with  moss.  Should  the  wound  have  become  closed  by  a 
dried  blood-clot  and  no  indications  of  infection  be  present,  this  scab 
can  be  left  undisturbed  and  the  fracture  allowed  to  heal  under  it.  A 
plaster-of-Paris  dressing  can  then  be  immediately  applied  over  the  anti- 
septic dressing.  Tliis  antiseptic  plaster-of-Paris  occlusive  dressing  is 
left  in  place,  if  no  fever  or  pain  in  the  wound  occurs,  for  two  or  three 
weeks  longer,  until  the  wound  has  healed,  and  is  then,  if  necessarj',  re- 
placed l)y  a  simple  plaster-of-Paris  dressing  until  complete  consolida- 
tion of  the  fracture  has  taken  place.  This  antiseptic  j)laster-of-Paris 
occlusive  dressing  has  been  recently  very  much  employed  for  fresh 
compound  fractures  with  small  wounds,  and  also  in  the  treatment  fol- 
lownng  osteotomies  of  the  rhachitic  extremities  of  children.  Bergmann, 
Reyher  and  others  obtained  brilliant  results  in  the  Turko-Russian  War 
with  this  same  form  of  dressing,  even  in  such  injuries  as  gunshot 
wounds  of  the  knee.  The  method  is  not  suitable  for  severe  compound 
fractures  with  extensive  wounds  of  the  soft  parts,  nor  for  cases  which 
are  not  perfectly  fresh  when  they  come  for  treatment. 

The  opinions  of  surgeons  still  differ  as  to  whether  the  antiseptic 
occlusion  carried  out  in  the  manner  above  described  should  likewise  be 
used  for  fresh  comminuted  fractures  with  a  small  cutaneous  wound,  or 
whether  the  wound  should  be  enlarged  and  the  splinters  extracted. 


1^  101.]  FRACTURES.  599 

At  all  events,  the  brilliant  results  obtained  by  Bergniann  and  Rejlicr 
in  the  Turko-Kussian  War  show  that  the  primary  extraction  of  the- 
fragments,  formerly  so  much  insisted  upon  in  comminuted  fractures,  is 
not  always  necessary  ;  that  the  above-described  simple  antiseptic  occlu- 
sion, without  enlarging  the  wound  and  without  extraction  of  the  frag- 
ments, gives  even  here  excellent  results ;  and  that  the  splinters,  though 
very  numerous,  are  capable  of  healing  up  completely  in  the  wound, 
provided  the  wound  runs  an  antiseptic  course. 

2.  The  Antiseptic  Management  of  Severe  Compound  Fractures,  with 
extensive  injury  to  the  soft  parts,  likewise  consists  in  a  thorough  disin- 
fection of  ever}^  portion  of  the  wounded  surface  and  of  the  surround- 
ing parts  to  a  considerable  distance  from  the  wound.  If  the  opening 
into  the  wound  is  not  large  enough  to  ])ermit  of  careful  examination 
or  disinfection  of  the  entire  wound  cavity,  it  should  be  enlarged  with 
the  knife,  using  for  the  extremities  Esmarclfs  artificial  ischa^niia.  The 
point  of  fracture  is  inspected,  and  the  entire  cavity  of  the  wound  is 
energetically  irrigated  witli  a  one-tenth-per-cent.  solution  of  bichloride  of 
mercury,  crushed  shreds  of  tissue  are  cut  off  with  the  scissors  and  for- 
ceps, the  hsemorrhage  carefully  arrested,  foreign  bodies,  bullets,  etc., 
are  removed,  and  long,  deep  pockets  under  the  skin  or  deeper  parts  are 
split  open.  If  necessary,  the  fragments  may  be  drawn  out  of  the 
wound  with  sharp  hooks  or  bone  forceps,  to  render  it  possible  to  sys- 
tematically examine  and  disinfect  them  and  the  soft  parts  lying  behind 
them.  Counter-oi^enings  are  made  for  the  admission  of  short,  large- 
sized  drainage  tubes  to  the  most  deeply  lying  parts,  and  every  niche, 
every  recess  in  the  wound,  and  every  pocket,  should  be  carefully  drained 
or  split  open.  The  deep  drains  should  always  extend  to  the  cleft  in 
the  bone,  but  should  not  lie  between  the  fragments.  Tamponing  the 
wound  with  iodoform  gauze  or  sterilised  mull  supplies  excellent  drain- 
age. If  splinters  are  present,  all  those  which  are  entirely  loose  and 
dead  should  be  removed,  while  those,  on  the  other  hand,  which  are 
still  alive  and  attached  to  the  periosteum  should  be  retained,  and,  if 
displaced,  returned  to  their  normal  position.  Projecting  points  on  the 
fragments  which  interfere  with  reduction  should  be  removed  with  the 
bone  forceps  or  saw.  If  it  is  difficult  to  maintain  the  fragments  in 
position  after  their  reduction,  they  may  be  secured  in  their  normal  sit- 
uation by  sutures  through  the  ends  of  the  bone,  or  by  nailing  them 
together  aseptically  (see  page  597). 

After  the  wound,  with  all  its  recesses,  has  been  very  carefully  dis- 
infected and  drained,  we  proceed  to  insert  the  sutures,  provided  the 
case  is  one  suited  for  primary  union.  I  l)elieve  it  is  wiser  not  to  suture 
wounds  of  this  kind,  but  to  leave  them  open  and  pack  them  with  iodo- 


600  INJURIES   AND  SURGICAL   DISEASES   OP  BONE. 

form  gauze  or  sterilised  mull,  over  which  is  placed  au  antiseptic 
protective  dressing. 

Resection  of  the  Broken  Ends. — Formerlj^,  in  the  case  of  compound 
comminuted  fractures  of  the  long  hollow  bones,  the  splintered  ends  of 
the  bone  were  frequently  removed  (so-called  resection  in  continuity). 
This  primary  resection  immediately  after  the  injury  is  only  applicable 
for  the  most  severe  cases.  If,  during  the  subsequent  course  of  com- 
pound comminuted  fractures,  necrosis  of  the  broken  ends  takes  place, 
then  secondary  resection  of  the  fragments  is  indicated  to  obtain  more 
rapid  healing. 

Treatment  of  Compound  Fractures  of  Joints. — If  we  have  to  deal  with 
a  compound  fracture  of  a  joint,  we  proceed  according  to  the  same  prin- 
ciples— -i.  e.,  the  joint  is  exposed  by  a  sufficiently  long  incision,  carefully 
disinfected,  and  drainage  provided  for.  When  necessary,  we  also  re- 
move any  crushed  fragments  of  bone,  extract  the  free  splinters,  or,  in  the 
severest  cases,  perform  total  resection  of  the  articular  ends  of  the  bones. 
Speaking  generally,  resection  in  compound  fractures  of  a  joint  is  gov- 
erned by  the  following  principles  (see  §  -40) :  Primary  resection  is  in- 
dicated in  fresh,  non-infected,  extensive  comminuted  fractures  of  the 
articular  ends  of  the  bones,  accompanied  by  great  injury  to  the  soft 
parts.  Compound  fractures  involving  a  joint  with  only  a  small  cuta- 
neous wound,  after  careful  disinfection  of  the  latter,  should  be  treated 
at  first  as  though  the  fracture  were  subcutaneous.  If  the  attempt  fails, 
and  inflammation  or  suppuration  of  the  joint  with  fever  comes  on,  then 
arthrotomy  should  be  performed — i.  e.,  the  joint  is  opened  freely,  the 
fracture  exposed,  carefully  disinfected,  and  drained.  Not  infrequently, 
under  these  conditions,  fixation  of  the  fragments  by  sutures  or  nails 
renders  excellent  service.  Whether  a  typical  resection  of  the  broken 
articular  extremities  should  be  performed  depends  upon  the  character 
and  severity  of  the  injury  to  the  bone  and  the  extent  of  suppuration  or 
infection.  At  all  events,  resection  is  indicated  when  fever  and  local 
inflammation  continue  after  arthrotomy  and  drainage  of  the  joint,  and 
when  there  is  a  prol)ability  of  a  severe  infection  of  the  wound  of  the 
bone  having  taken  place. 

Subsequent  Treatment  of  Compound  Fractures. — The  rest  of  the  treat- 
ment of  compound  fractures  depends  upon  their  subsequent  behaviour. 
In  the  most  favourable  cases,  running  a  course  free  from  fever,  the 
first  dressing  is  left  in  place  six  to  eight  to  ten  to  fourteen  days  and 
then  changed,  and  at  the  same  time  any  drains,  sutures,  or  tampons  are 
removed.  If,  on  the  other  hand,  fever  should  occur,  or  the  patient 
complain  of  pain  in  the  wound,  the  dressing  should  be  immediately 
changed  and  the  wound  and  parts  surrounding  it  carefully  examined 


§101.]  FRACTURES.  601 

for  the  presence  of  retained  discharges,  which  sliould  be  immediately 
let  out  by  an  incision.  The  granulating  wound  should  also  be  treated 
strictly  according  to  antiseptic  ])rinciples,  and  a  closed  or  fenestrated 
plaster  splint,  or  one  of  the  modifications  given  under  §  54,  applied 
until  the  wound  has  become  covered  with  skin.  AYe  cover  large 
granulating  surfaces  with  skin  by  Thiersch's  method  of  skin  grafting. 
When  the  wound  has  healed,  a  closed  plaster  splint  is  applied,  if  neces- 
sary, until  consolidation  of  the  fracture  is  complete. 

3.  Treatment  of  Fractures  which  are  not  Fresh  and  have  become 
Septic. — AVe  count  all  cases  as  not  "fresh"  which  come  under  obser- 
vation twenty-four  to  forty-eight  hours  after  the  injury,  with  already 
existing  local  inflammatory  changes  in  the  wound.  Of  course,  the 
character  of  these  cases  varies  greatly,  according  to  the  severity  and 
nature  of  the  reaction  which  is  present  in  the  wound.  If  the  reaction 
in  the  wound  is  slight,  an  aseptic  course  of  repair  may  not  infre- 
quently be  obtained  by  energetically  disinfecting,  enlarging,  and  drain- 
ing the  wound  and  then  applying  an  antiseptic  occlusive  dressing. 
Tamponing  the  cavit_y  of  the  wound  with  iodoform  gauze  or  sterilised 
mull,  and  omitting  all  sutures,  is  a  procedure  particularly  applicable 
for  such  cases. 

In  other  instances,  again,  the  reaction  in  the  wound  will  have  al- 
ready become  very  marked.  There  is  pronounced  decomposition  and 
putrefaction  of  the  discharges,  and  the  crushed  soft  parts  and  cellular 
tissue  are  gangrenous,  and  saturated  with  the  products  of  decomposi- 
tion. The  suppuration  and  putrefaction  which  are  present  are  no 
longer  limited  to  the  wound,  but  have  begun  to  spread  progressively. 
Not  infrequently  there  is  such  a  large  accumulation  of  putrefactive 
gases  that  a  pronounced  gaseous  infiltration  (emphysema)  takes  place. 
Even  in  such  unfavourable  cases  of  pronounced  sepsis  a  vigorous  dis- 
infection of  all  the  septic  tissues  should  be  undertaken  and  incisions 
made  in  great  numbers.  AVe,  of  course,  avoid  applying  the  ordinary 
closed  protective  dressings  which  exert  pressure,  and  content  ourselves 
with  energetic  disinfection  of  the  wound,  covering  it  with  sterilised 
gauze  or  iodoform  gauze,  or  employing  permanent  antiseptic  irrigation 
(see  page  178).  As  long  as  the  treatment  lasts  it  is  exceedingly  impor- 
tant to  keep  the  extremity  in  an  elevated  position  and  the  fragments  as 
securely  immobilised  as  possible.  When  the  wound  has  become  aseptic 
and  is  granulating,  we  cover  it  with  iodoform  gauze  and  cotton  and 
immobilise  the  fragments  by  a  suitable  splint,  or  by  a  fenestrated  or 
interrupted  plaster-of-Paris  dressing.  The  treatment  of  compound 
fractures  which  have  become  infected  demands  much  patience  and 
care,  and,  above  all,  experience.     It  is  very  important  to  note  the  be- 


(502  INJURIES  AND   SURGICAL   DISEASES   OF   BONE. 

Lavionr  of  the  temperature  bv  means  of  the  constant  use  of  the  ther- 
mometer, and  to  recognise  any  retention  of  discharges  at  the  earliest 
possible  moment  and  to  let  them  out  by  incisions. 

Indications  for  Amputation  and  Disarticulation. — In  which  cases  of  com- 
pound fracture  should  amputation  or  disarticulation  of  the  injured  limb  be 
performed  i  Imuiediate  amputation  or  disarticulation  of  the  injured  limb 
directly  after  the  reception  of  the  injury,  or  within  the  ^rsi  twenty -foiir  to 
forty -eight  hours,  before  the  reaction  in  the  wound  sets  in,  is  only  indicated 
in  cases  of  \evj  severe  crushing  of  the  bone  with  extensive  injury  to  the  soft 
parts  (primary  amputation).  With  the  aid  of  the  antiseptic  method  of 
treating  wounds  we  are  enabled  to  carry  out  conservative  treatment  success- 
fully in  cases  where  formerly  preservation  of  the  injured  limb  would  have 
been  impossible.  The  opening  of  a  large  joint  or  injury  of  large  arteries  and 
nerves  do  not  in  themselves  indicate  primary  amputation,  though  it  should 
be  immediately  performed  if  the  soft  parts,  muscles,  vessels  and  nerves  are  so 
extensively  lacerated  and  crushed  that  preservation  cf  the  limb  is  impossible 
or  gangrene  is  sure  to  follow.  The  decision  as  to  whether  amputation  should 
be  immediately  performed  or  not  is  not  always  easy.  After  having  deter- 
mined upon  amputation,  we  perform  it  through  sound  tissues  which  have  not 
been  cnished,  and  take  the  greatest  care  to  avoid  fashioning  the  flaps  which 
are  to  cover  the  amputation  wound,  from  the  contused  portions  of  skin  or 
those  portions  that  have  been  torn  loose  from  the  underlying  parts. 

Amputation  is  also  indicated  in  the  case  of  many  infected  compound  frac- 
tures when  the  local  wound  infection,  the  suppuration,  putrefaction,  etc  ,  have 
become  so  extensive  as  to  render  preservation  of  the  limb  impossible,  or  when 
severe  manifestations  of  general  septic  infection  make  their  appearance.  In 
such  cases  we  amputate — in  other  words,  we  remove  the  source  of  infection 
in  order  to  save  the  life  of  the  patient.  Delay  in  such  cases  is  dangerous, 
and  the  sooner  amputation  is  performed  in  the  presence  of  high,  septic  fever, 
the  better  is  the  prospect  of  recovery.  In  the  later  stages  of  compound  frac- 
tures amputation  is  indicated,  especially  when  there  is  extensive  suppurative 
inflammation  of  the  medulla  of  the  bone  or  of  the  joints,  or  when  the  patient 
is  in  danger  of  exhaustion  from  severe  suppuration,  etc.  Briefly  speaking, 
we  amputate  when  the  condition  of  the  extremity  is  such  that  healing  can- 
not be  expected  from  conservative  treatment. 

After-treatment  of  Fractures. — The  after-treatment  is  directed  prin- 
cipally towards  the  joints  and  the  disturbances  in  nutrition  wliich  oc- 
cur in  the  soft  paits.  particularly  the  skin  and  muscles.  A^ery  often  no 
special  after-treatment  is  necessary  when  consolidation  of  the  fracture 
is  completed.  Massage,  diligent  exercise  of  the  muscles,  and  active  and 
passive  motion  of  the  joints  will  usually  soon  remedy  the  muscular 
weakness  and  the  stiffness  of  the  joints,  and  the  sooner  these  measures 
are  adopted  the  better.  A  warning  should  be  given  against  the  too 
protracted  use  of  retentive  dressings  for  fractures,  on  account  of  the 
atrophy  of  the  muscles  and  the  disturbances  in  the  functions  of  the 


§101.]  FRACTURES.  603 

joints  wliich  they  cause.  In  the  case  of  old  people  particularly  it  is 
often  necessary  to  j^ive  up  the  coniinenient  to  bed  hecause  of  the  threat- 
ening hypostasis  or  disturbance  of  tlie  general  health,  and  to  permit 
them  to  move  about,  even  with  fractures  of  the  lower  extremity,  on 
crutches,  and  with  suitable  splints  and  a  raised  sole  under  the  foot  of 
the  sound  leg  (see  page  596).  In  proper  cases,  such  as  in  fractures  of 
the  radius  with  the  ulna  intact,  or  of  the  fibula  with  the  tibia  intact, 
massage  can  be  begun  at  a  very  early  period — within  the  first  or  sec- 
ond week,  for  instance — and  a  more  ]-apid  recovery  will  thus  be  ob- 
tained. Of  course,  the  above-mentioned  fractures  must  be  immobilised 
a  long  enough  time — two  to  three  weeks  at  least — by  proper  splints. 
Baths  and  rubbing  with  alcohol  are  also  of  use.  If  there  is  much 
oedema,  particularly,  for  example,  in  the  case  of  the  lower  extremity, 
the  latter  should  be  enveloped  in  a  tight  fiannel  bandage,  or  retentive 
dressings  which  can  be  readily  removed  should  be  applied  (Figs.  201, 
205).  If  a  long  time  has  elapsed  since  consolidation  of  a  fracture  in  the 
extremities,  and  if  the  stiffness  of  the  joints  and  atrophy  of  the  muscles, 
owing  to  lack  of  energy  on  the  part  of  the  patient  or  physician,  has 
become  very  pronounced,  it  is  all  the  more  difficult  to  restore  the  nor- 
mal function.  In  such  cases  it  is  sometimes  best  to  repeatedly  anaes- 
thetise the  patients  for  the  purpose  of  moving  the  joints  and  performing 
vigorous  massage.  It  is  in  just  these  cases  that  massage  not  infre- 
quently yields  most  brilliant  results.  In  these  old  cases,  where  motion 
is  impaired  and  there  are  contractures  and  muscular  atrophy,  method- 
ical exercises  by  means  of  the  mechanical  appliances  in  the  orthopaedic 
institutes  are  exceedingly  valuable.  If  we  have  to  deal  with  ischsemic 
contractures  and  paralyses,  they  should  be  treated  according  to  the  rules 
mentioned  on  page  550. 

Treatment  of  the  Complications. — The  treatment  of  the  above-men- 
tioned complications  is  described  in  previous  paragraphs  —  shock  in 
§  63,  delirium  tremens  in  §  64,  infectious  diseases  of  wounds  in  §§  66- 
75,  and  gangrene  in  §  100,  etc. 

Treatment  of  Delayed  Callus  Formation  and  Pseudarthrosis. — For 
these  conditions  the  following  methods  are  particularly  valuable :  1. 
E.ubl)ing  together  the  ends  of  the  bones  (Celsus),  according  to  Karmi- 
low,  was  successful  only  forty  times  in  four  hundred  and  thirty  cases. 
In  this  method,  which  is  suited  more  for  cases  with  delayed  callus  for- 
mation, the  fragments  are  rubbed  together  daily  until  a  sufficient  local 
reaction  has  set  in  and  the  point  of  fracture  is  tender  on  pressure.  A 
plaster-of- Paris  dressing  is  then  applied.  Patients  with  fracture  of  the 
lower  extremity  can  be  allowed  to  move  about  in  a  retentive  dressing 
for  the  purpose  of  maintaining  an  inflammatory  irritation  at  the  point 


604  INJURIES  AND  SURGICAL   DISEASES  OP  BONE. 

of  fracture.  2.  Artificial  increase  of  bone  formation  by  the  production 
of  a  venous  hyperaemia  at  the  point  of  fracture  by  tying  off  the  extrem- 
ity on  the  proximal  side  of  the  fracture  with  a  rubber  tourniquet  drawn 
moderately  tight.  In  order  that  the  hypersemia  may  be  localised  at  the 
point  of  fracture  the  extremity  above  and  below  it  can  be  enveloped  in 
a  bandage  (Dumreicher,  Ilelferich,  etc.).  The  procedure  can  be  com- 
bined with  the  application  of  a  plaster  or  other  kind  of  splint,  and  it  is 
here  also  a  good  plan  to  permit  patients  with  fracture  of  the  lower  ex- 
tremity to  move  about  in  a  proper  dressing.  3.  Le  Fort  has  success- 
fully employed  electrolysis — i.  e.,  two  platinum  needles  connected  with 
a  constant  battery  are  stuck  into  the  false  joint.  The  needle  fastened 
to  the  positive  pole  is  kept  in  one  place,  while  that  fastened  to  the  nega- 
tive pole  is  introduced  repeatedly  at  several  different  points.  4.  The 
employment  of  various  other  means  of  irritation  has  been  abandoned 
(irritation  of  the  skin,  subcutaneous  injections  of  irritating  chemical 
liquids,  etc.),  Nevertheless,  Mikulicz  has  used  oil  of  turpentine  with 
excellent  results.  After  making  a  longitudinal  incision  through  the 
soft  parts  and  periosteum,  the  latter  is  freed  from  almost  the  entire  cir- 
cumference of  the  bone  with  the  raspatory  to  a  distance  of  about  ten 
centimetres  from  the  point  of  fracture,  and  gauze  saturated  with  oil  of 
turpentine  is  placed  between  the  bone  and  periosteum  and  changed 
every  three  to  five  days  until  the  wound  has  healed.  As  yet,  Berg- 
mann  has  seen  no  case  of  pseudarthrosis  cured  by  the  oil-of-turpentine 
treatment.  5.  Irritation  of  the  ends  of  the  bones  by  driving  ivory  pegs 
into  them  (Dieffenbach)  is  performed  in  the  following  manner :  After 
the  soft  parts  above  and  below  the  point  of  fracture  have  been  divided 
with  the  knife,  holes  are  bored  in  the  bone  with  a  drill,  and  one  or 
two  ivory  pegs,  according  to  the  size  of  the  bone,  are  driven  into  each 
fragment.  The  extremity  is  then  encased  in  a  plastei-  dressing,  which 
may  be  fenestrated  or  not.  The  ivory  pegs  are  allowed  to  remain  two 
to  three  weeks  or  longer.  Karmilow  states  that  the  procedure  when 
applied  to  the  thigh  and  arm  has  been  successful  in  43"5  per  cent,  of 
the  cases,  while  for  the  leg  and  forearm  the  number  of  cures  have 
amounted  to  eighty  per  cent.  Instead  of  ivory  pegs,  Riedinger  has 
recommended  bone  pegs,  which  are  capable  of  becoming  firmly  adher- 
ent to  the  bones. 

If  the  procedures  hitherto  described  do  not  prove  successful,  there 
is  nothing  left  but  to  expose  the  false  joint  with  the  knife,  to  freshen 
the  ends  of  the  bones,  to  resect  them,  and  then,  when  necessary,  to 
fasten  them  together  by  sutures  of  catgut,  sterilised  silver  wire,  iron 
wire,  or  silkworm  gut,  or  by  nails.  The  ends  of  the  bones  can  be 
freshened  by  resecting"  them  in  the  form  of  steps   and  thus  fitting 


§  101.]  FRACTURES.  605 

tliem  together ;  or  the  pointed  end  of  one  fragment  can  be  introduced 
into  the  medullary  cavity  of  the  other  (see  page  111,  Fig.  94).  Expo- 
sure of  the  false  joint,  followed  by  freshening  the  ends  of  the  bones 
and  uniting  them  with  sutures  or  nails,  is  the  safest  method  of  treating 
all  false  joints  of  long  standing,  and  if  carried  out  with  antiseptic  pre- 
cautions it  is  entirely  free  from  danger.  For  nailing  the  bones,  we 
use,  as  was  said  before,  long,  four-cornered  steel  nails,  which  are  ren- 
dered perfectly  sterile  by  polishing,  boiling  for  fifteen  minutes  in  a 
one-per-cent.  soda  solution,  heating  red-hot,  and  storing  in  a  ten-per- 
cent, solution  of  carbolic  acid  in  glycerine.  After  nailing  the  bones 
together,  an  antiseptic  protective  dressing  is  placed  over  the  wound, 
which  is  left  open,  and  a  gypsum  dressing  is  applied  on  the  outside. 
The  nails  are  removed  at  the  end  of  the  third  or  beginning  of  the 
fourth  week. 

Treatment  of  Losses  of  Bone  Substance — Transplantation  of  Bone. — If 
a  considerable  loss  of  substance  has  occurred  in  one  of  the  two  bones 
of  the  forearm  or  leg,  we  may  either  chisel  out  of  the  other  bone  a 
piece  corresponding  in  size  to  the  defect,  and  cause  the  ends  of  the 
bones  to  unite,  with  a  corresponding  amount  of  shortening,  or  we 
may  adopt  Nussbaum's  plan,  and,  after  freshening  the  ends  of  the 
bone,  fill  up  the  defect  caused  by  the  loss  of  substance  with  one  or  two 
pedunculated  bone-periosteal  flaps.  In  proper  cases,  as,  for  example, 
on  the  skull,  a  loss  of  bone  substance  is  repaired  by  pedunculated  skin- 
bone  flaps  taken  from  the  vicinity  of  the  defect,  the  bone  being  cut 
from  the  outer  tablet  (see  Special  Surgery).  We  can  also  transplant 
into  the  defect,  as  MacEwen,  Oilier,  Bergmann,  and  others  do,  several 
free  pieces  of  bone,  from  0'3  centimetre  to  0'5  centimetre  in  length, 
retaining  their  periosteum  and  medulla ;  or  we  can  use  for  this  pur- 
pose a  small  hollow  bone  like  the  first  phalanx  of  the  great  toe,  as 
described  on  page  586.  The  bone  material  used  for  transplantation 
must  be  taken  while  it  is  still  undergoing  active  growth,  and,  conse- 
quently, from  young  subjects  or  newborn  infants,  and  suppuration 
must  be  prevented  by  the  strictest  asepsis.  Losses  of  bone  substance 
have  also  been  successfully  repaired  by  pieces  of  decalcified  bone  (see 
pages  586,  587,  Transplantation  of  Bone).  In  one  case  where  there 
was  a  loss  of  substance  in  the  tibia,  Hahn  successfully  implanted  the 
fibula  into  the  tibia. 

The  internal  administration  of  lime,  or,  what  is  better,  of  phos- 
phorus (Wegner),  has  been  recommended  for  pseudarthrosis.  Any 
constitutional  or  local  anomaly  which  may  be  present  must  always,  of 
course,  be  taken  into  consideration. 

If  all  methods  of  treatment  prove  unsuccessful,  care  must  be  taken 


606  INJURIES   AND  SURGICAL   DISEASES  OF   BONE, 

to  alleviate  the  disturbance  of  function,  as  far  as  possible,  by  a  suitable 
splint  apparatus.  If  the  peripheral  portion  of  the  limb  has  become  so 
atrophic  and  flail-like  as  to  render  the  wearing  of  a  supporting  appli- 
ance scarcely  possible,  amputation,  particularly  if  it  is  the  lower 
extremity  which  is  involved,  is  indicated. 

The  Erosion  of  an  Ivory  Peg  which  has  been  driven  into  a  Bone.— It  is 

well  known  that  ivory  pegs  which  have  been  driven  into  a  bone  become 

roughened  and  appear  as 
though  portions  of  their  sur- 
face had  been  gnawed  away 
(Fig.  347).  Polynuclear  giant 
cells  are  found  in  the  small 
cavities,  and  the  same  oste- 
oclasts which  are  present  dur- 
ing the  normal  process  of 
bone  absorption.  The  cause 
of  this  lacunar-bone  absorp- 
tion is  partly  to  be  ascribed 
to  the  action  of  an  acid  and 

partly  to  the  pressure  of  the 

riG.347.-Erosion  («)^«f  ^^j^.  ^^"^^  P^g  ^y  the  action  of     ^^^^^^^  ^^^   ^^^^  ^^^j^  ^^  ^^^ 

surrounding  tissues.  I  have 
shown  that  it  is  probably  the  carbonic  acid  which,  in  statu  nascendi,  during 
the  metabolism  of  the  tissvies,  sets  free  the  lime  in  the  ivory  peg,  and  that  then 
the  decalcified  ground  substance  which  is  left  behind  is  dissolved  by  the  alk- 
aline fluids  in  the  tissues  (see  page  583). 

The  Treatment  of  Fractures  which  have  healed  with  Deformity. — 

Deformity  in  the  healing  of  a  fracture  should  be  prevented  by  careful 
supervision  of  the  point  of  fracture,  or,  in  other  words,  of  the  position 
of  the  fragments  while  the  process  of  healing  is  going  on.  The  reten- 
tive dressing  should  be  changed  too  often  rather  than  too  infrequently. 
If  a  fracture  heals  with  so  marked  a  displacement  as  to  produce  serious 
disturbance  of  function,  the  bones  should  either  be  refractured  or  the 
point  of  fracture  exposed,  chiselled  through,  and  the  ends  of  the  bones 
then  reunited  in  a  good  position.  Those  cases,  as  a  general  thing,  are 
least  amenable  to  treatment  which  have  healed  with  considerable  dis- 
locatio  ad  longitudinem.  The  bones  are  broken  under  chloroform  an- 
aesthesia either  by  hand  or  by  some  special  apparatus.  The  machines 
used  for  directly  fracturing  the  bones  are  called  osteoclasts ;  the  ones 
invented  by  Rizzoli  and  by  Collin  and  Robin  are  very  useful  (see  page 
84).  The  open  division  of  fractures  which  have  healed  with  deformity 
is  carried  out  by  making  an  incision  through  the  soft  parts,  thus  expos- 
ing the  point  of  fracture,  and  then  dividing  the  bone  with  the  hanmier 
and  chisel  (osteotomy).     The  bone  is  not  chiselled  entirely  throngh. 


g  102.]  CONTUSIONS  AND   WOUNDS  OP  BONE.  607 

but  a  small  portion  is  left,  M-liicli  is  broken  by  hand.  When  necessar}', 
a  wedge-shaped  piece  must  be  chiselled  out  of  the  deformed  l)one.  Os- 
teotomy of  the  bone  is  absolutely  free  from  danger  if  the  rules  of  ase])- 
sis  are  carefully  observed.  The  wound  is  not  sutured,  but  left  open 
and  packed  with  sterilised  gauze,  and  directly  over  the  protective  dress- 
ing a  plaster  splint  is  ap})lied,  which  is  left  in  place  until  the  wound  has 
healed,  though  it  is  changed  earlier  if  there  is  need  of  doing' so.  In 
cases  of  considerable  shortening  from  mal-union  of  a  fracture,  the  use 
of  extension  by  a  weight,  after  performing  osteotomy,  is  very  much  to 
be  recommended.  Badly  nnited  fi-aetnres,  of  tlie  femur  for  instance, 
occurring  in  adults  and  accompanied  b}'  much  shortening,  sometimes 
require  powerful  extension  (by  a  weight  amounting  to  twenty  to 
twenty-five  to  thifty  pounds),  and  surprisingly  good  results  may  be  ob- 
tained, as  both  Schede  and  myself  have  observed.  Under  certain  cir- 
cumstances Schede  recommends  increasing  the  weight  used  for  exten- 
sion in  the  case  of  adults  to  as  much  as  forty  pounds. 

Moritz  and  Meyer  have  used  the  electric  current  with  success  for 
exuberant  callus  (callus  luxuriansX  -; 

§  102.  Contusions  and  Wounds  of  Bone. — If  a  bone  is  crushed  by  a 
blow  from  a  blunt  object,  we  have  especially  to  consider,  in  addition  to 
'the  contusion  of  the  bone  substance,''the  injury  to  the  overlying  soft 
parts,  the  skin, 'the  subcutaneous  cellular  tissue,  and 'the  periosteum. 
The  course  of  contusions  of  the  soft  parts  is  described  in  §  92.  Con- 
tiisions  of  periosteum  lead  to  a  greater  or  less  extravasation  of  blood 
into  and  particularly  beneath  the  periosteum,  which  is  called  a  hsema- 
toma  of  the  periosteum.  These  periosteal  and  subperiosteal  extravasa- 
tions of  blood  usually  terminate  by  being  gradually  absorbed.  Not 
infrequently  there  develops,  at  the  point  where  the  periosteum  has  been 
contused,  a  traumatic,  ossifying  periostitis,  in  consequence  of  which  the 
bone  becomes  only  temporarily  thickened. 

The  anatomical  changes  which  occur  in  contusions  of  bone  tissue 
proper  consist  in  a  more  or  less  pronounced  compression  or  splintering 
of  tlie  bone  substance,  such  as  happens  after  a  thrust  or  blow,  and  to  a 
marked  degree  in  every  fracture.  "In  the  medullary  cavity  an  extrava- 
sation of  blood  is  found  proportionate  in  size  to  the  amount  of  violence 
exhibited.  As  is  the  case  with  fractures,  the  course  of  contusions  of 
the  periosteum,  bone,  and  medullary  tissue  depends  mainly  upon 
whether  an  external  wound  is  present  or  not.  Only  in  the  most  ex- 
ceptional instances  of  subcutaneous  contusions  of  bone  do  inflammatory 
or  suppurative  processes  occur,  and  when  they  do,  it  is  owing  to  the 
deposit  of  micro-organisms  from  the  blood  in  the  contused  portions  of 
bone  and  medullary  tissue,. or  to  the  extension  to  the  deeper  parts  of 


608  INJURIES   AND   SURGICAL   DISEASES  OF   BONE, 

inflammatory  processes  existing  in  the  contused  skin.  Primary  acute 
infections  osteomyelitis  is  probably  sometimes  caused  by  such  a  con- 
tusion of  the  medullary  and  cortical  tissue.  It  is  a  well-known  fact 
that  tuberculosis  may  originate  from  some  slight  contusion  of  the 
bone,  particularly  in  the  case  of  children,  for  the  reason  that  the  tuber- 
cle bacillus  finds  in  contused  tissues  and  extravasations  of  blood  condi- 
tions which  are  favourable  to  its  development.  The  vascular  arrange- 
ment in  the  medulla  is  such  that  solid  impurities  in  the  blood  readily 
become  deposited.  The  inflammation  of  bone  to  which  mother-of-pearl 
turners  are  subject  is  an  instance  of  this  (see  page  618). 

The  treatment  of  subcutaneous  contusions  of  periosteum  and  bone 
consists  at  first  in  placing  the  injured  part  in  a  suitable  (elevated)  posi- 
tion, in  the  application  of  ice,  and  later  in  employing  massage  to  pro- 
mote absorption  of  the  blood  extravasated  in  the  periosteum  and  soft 
parts.  Inflammatory  complications,  suppuration,  etc.,  are  treated  ac- 
cording to  the  general  rules  laid  down  in  §§  68-71. 

Open  Wounds  of  Bone. — The  open  wounds  of  bone  have  lost  the 
danger  that  used  to  attend  them  before  the  introduction  of  the  antisep- 
tic method  of  treating  wounds.  By  the  latter  means  all  infection  is 
avoided,  and  even  deep  wounds  which  penetrate  into  the  medullary 
cavity  heal  without  complications.  The  most  common  wounds  of  bone 
are  those  occurring  in  fractures.  True  wounds  of  bone  are  such  as 
are  caused  by  a  blow,  or  a  thrust  with  a  sabre,  knife,  axe,  etc.  In  con- 
sequence of  this  violence  there  may  be  produced  in  the  skull  for  ex- 
ample, the  fissures  or  cracks,  mentioned  under  Incomplete  Fractures, 
which  divide  the  bone  either  partially  or  completely.  On  the  extremi- 
ties, particularly  the  fingers,  complete  division  of  the  bone  and  soft 
parts  is  frequently  observed.  Now  and  then,  by  paying  strict  atten- 
tion to  antisepsis,  phalanges  or  finger  tips  which  have  been  entirely 
severed  may  be  sutured  in  place  and  caused  to  reunite.  Careful  sub- 
cutaneous suturing  of  the  periosteum  with  catgut  and  absolute  immo- 
bilisation of  the  ajffected  part  are  of  _chief  importance.  I  once  saw  a 
terminal  phalanx  which  had  reunited  in  this  way  come  off  again  four 
weeks  later  in  consequence  of  a  violent  blow,  and  then  it  could  not  be 
made  to  heal  on  a  second  time.  If  a  piece  has  been  taken  out  of  the 
continuity  of  a  bone  by  a  sabre  cut,  for  example,  and  there  is  no  peri- 
osteum left  at  the  spot  in  question,  thp  bone  will  granulate  very  soon, 
and  skin  will  gradually  form  over  the  granulating  surface.  Very  often 
the  loss  of  substance  in  a  bone  of  the  skull  is  not  completely  replaced 
by  new  bone,  and  persists  as  a  more  or  less  appreciable  gap. 

The  repair  of  a  wound  in  bone  is  essentially  the  same  as  that  which 
takes  place  in  fractures,  and  is  described  on  page  580.    Gunshot  wounds 


§104.]  ACUTE   INFLAMMATIONS  OF   BOXI^.  609 

of  bone  and  soft  parts  will  be  discussed  in  conjunction  witli  injuries 
of  joints  (see  >^  124). 

j<  10;^.  The  Inflammations  of  Bone. — The  intlainniations  of  bone  gen- 
erally begin  in  the  periosteum  and  in  the  medulla  in  the  form  of  a 
periostitis  and  osteomyelitis.  From  these  regions  the  inflammation 
extends  to  the  bone  substance  proper  and  to  the  epiphyseal  or  articular 
cartilages,  giving  rise  to  a  true  ostitis  or  chondritis.  The  ostitis  mani- 
fests itself  either  as  an  absorption  of  bone  (rarefying  ostitis)  or  as  a 
new  formation  of  bone  (condensing  ostitis).  The  inflammatory 
changes  in  the  bone  proper  take  place  in  the  parts  surrounding  the 
vessels  and  in  the  medullary  spaces.  The  pathological  absorption  of 
bone  is,  as  a  rule,  analogous  to  the  normal  absorption — i.  e.,  it  takes 
place  in  the  form  of  pit-like  depressions,  the  so-called  Howship's  lacunae 
(lacunar  absorption  of  bone),  which  are  hollowed  out  of  the  bone  by  the 
action  of  poly  nuclear  cells — the  osteoclasts,  as  they  are  called  (Kolliker, 
Fig.  343).  In  this  lacunar  absorption  of  bone  the  lime  salts  and  the 
ground  substances  are  always  dissolved  more  or  less  simultaneously. 
In  a  second  form  of  absorption  of  bone — in  halisteresis  ossium — the 
lime  salts  become  at  first  dissolved,  the  decalcified  ground  substance  of 
the  bone  persisting  for  some  time  longer.  The  latter  kind  of  absorp- 
tion of  bone  takes  place  especially  in  osteomalacia  (see  §  109).  The 
chancres  which  occur  in  inflammation  of  cartilajje  consist  mainly  in  a 
proliferation  of  the  cartilage  cells  and  in  a  fibrillary  degeneration  and 
necrosis  of  the  ground  substance  of  the  cartilage. 

§  104.  Acute  Inflammations  of  Bone,  Acute  Periostitis,  and  Acute 
Osteomyelitis. — The  acute  inflammations  of  bone,  in  the  form  of  an 
acute  inflammation  of  the  periosteum  and  medulla  (acute  periostitis 
and  acute  osteomyelitis),  have  been  studied  in  their  simplest  form  in 
§  101,  under  the  subject  of  Callus  Formation  after  subcutaneous  frac- 
tures. In  every  instance  where  a  suppurative  periostitis  and  osteo- 
myelitis occurs  it  is  due,  like  any  acute  suppuration,  to  infection  by 
micro-organisms.  The  infection  has  either  taken  place  at  the  point 
where  the  injury  was  received,  as  in  the  case  of  compound  fractures 
which  are  not  treated  antiseptically  and  open  wounds  of  the  perios- 
teum, or  it  has  spread  from  a  suppurative  inflammation  of  the  sur- 
rounding parts,  or,  thirdly,  it "  origi nates  by  infectious  matter  being 
brought  from  another  portion  of  the  body  by  the  blood-vessels  and 
deposited  in  the  bone  (hasmatogenous  infection).  The  latter  kind 
includes  the  rnetastatic  inflammations  of  the  periosteum  and  medulla 
occurring  in  pyaemia,  typhoid  and  scarlet  fevers,  etc.  Such  acute  in- 
flammations of  the  periosteum  and  medulla  not  only  develop  in  the 

course  of  acute  infectious  diseases  from  metastasis  of  their  poisons,  but 
39 


610  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

also  occur  in  perfectly  healthy  individuals,  and  are  due  to  micro-organ- 
isms whicli  are  canned  to  the  bone  in  the  blood  from  the  external 
cutaneous  covering,  the  intestinal  tract,  the  lungs,  etc.,  and  there  excite 
tlie  various  kinds  of  inflammation. 

Acute  Infectious  Osteomyelitis. — The  severest  acute  inflammation  of 
bone  is  the  primary  acute  infectious  osteomyelitis  and  periostitis  (Liicke) 
iirst  described  by  Chassaignac  as  osteomyelite  spontanee  diffuse  des  os 
or  typhus  des  os  or  des  memhres.  This  is  chiefly  observed  in  young 
people.  Young  growing  bones,  as  a  general  thing,  possess  a  more  or 
less  pronounced  tendency  towards  inflammatory  processes.  An  active 
development  of  new  vessels  takes  place  in  growing  bone,  and  the  ter- 
minal loops  of  the  vessels  with  their  dilatations  lie  close  to  the  epi- 
physeal cartilage  ;  consequently  solid  impurities,  especially  micro-organ- 
isms, can  be  deposited  in  the  cartilage  from  the  retarded  blood  stream. 
Moreover,  the  filtration  and  deposition  of  micro-organisms  and  all  solid 
impurities  contained  in  the  blood  is  rendered  easy  in  the  medulla  of 
every  bone,  for  the  reason  that  the  blood  stream  is  not  confined  by  walls 
as  it  passes  through  the  sacculated  medullary  spaces.  Osteomyelitis  oc- 
curs most  commonly  in  the  femur  of  young  subjects,  possibly  because 
this  bone  grows  the  most  rapidly.  According  to  Haaga's  statistics,  cov- 
ering forty  years'  experience  in  the  clinic  at  Tiibingen,  the  disease  oc- 
curs more  frequently  in  men  than  in  women,  the  proportion  being  3-38 
to  1.  Acute  osteomyelitis  is  particularly  common  in  certain  regions, 
such  as  Switzerland,  the  mountainous  parts  of  South  Germany,  and  the 
coast  of  North  Germany.  Epidemics  of  very  severe  cases  occur  in  these 
places.  In  other  instances  acute  osteomyelitis  is  secondary,  and  occurs, 
for  example,  in  the  course  of  acute  infectious  diseases  such  as  measles, 
scarlet  fever,  small-pox,  or  typhoid  fever  (see  page  017).  We  shall  con- 
fine ourselves  at  present  mainly  to  the  primary  acute  osteomyelitis. 

Etiolo^  of  Primary  Acute  Osteomyelitis. — Our  knowledge  of  the  eti- 
ology of  primary  acute  infectious  osteomyelitis  has  recently  been  advanced, 
particularly  by  Kocher,  Rosenbach,  Kraske,  and  others.  It  has  been  found 
that  in  the  majority  of  cases  it  is  caused  by  the  yellow  pus  coccus,  the  staphy- 
lococcus pyogenes  aureus,  less  often  by  the  staphylococcus  pyogenes  albus 
(see  pages  321-325).  Occasionally  there  is  a  mixed  infection— i.  e.,  in  addi- 
tion to  the  staphylococcus  pyogenes  aureus  other  pus  cocci  will  be  present, 
especially  the  staphylococcus  pyogenes  albus  or  the  streptococcus  pyogenes. 
In  fifteen  cases  of  acute  osteomyelitis,  Rosenbach  found  the  staphylococcus 
pyogenes  aureus  fourteen  times,  once  with  the  chain  coccus  of  cellulitis,  and 
once  with  the  white  pus  coccus  (staphylococcus  pyogenes  albus).  In  only  one 
case  of  osteomyelitis  was  the  yellow  coccus  absent,  and  in  this  the  white  coc- 
cus alone  was  found.  In  nine  cases  out  of  twelve  Colzi  found  only  the  staphy- 
lococcus pyogenes  aureus,  and  in  three  instances  the  staphylococcus  albus  was 


§104.]  ACUTE   INFLAMMATIONS  OP   BONE.  fill 

also  present.  In  forty-flve  cases  of  osteomyelitis,  Lannclonf?ue  and  Aehard 
found  the  staphylococcus  pyogenes  albus  tweuty-eiglit  times,  the  staphylo- 
coccus albus  seven  times,  the  staphylococcus  aureus  and  albus  together  once, 
the  staphylococcus  citreus  once,  the  streptococcus  four  times,  i\w.  pneumococ- 
cus  twice,  and  twice  a  micro-organism  which  could  not  be  i)ositively  identified 
(pneumococcus  [?]).  The  staphylococcus  pyogenes  aureus,  and  particularly 
the  streptococcus  pyogenes,  are  more  virulent  than  the  staphylococcus  pyo- 
genes albus.  Osteomyelitis  can  also  be  produced  by  the  intravenous  injection 
of  the  bacterium  which  produces  lactic  acid,  by  typhoid  bacilli,  pneumococci, 
etc.  Like  any  other  acute  infiammation  and  suppuration,  osteomyelitis  can 
be  excited  experimentally  in  animals  by  agents  having  a  purely  chemical  ac- 
tion, such  as  turpentine  or  sterilised  cultures,  the  latter  producing  their  effect 
through  the  chemical  products  resulting  from  the  metabolism  of  the  pus  cocci 
(Ullmann).  In  short,  osteomyelitis  can  be  excited  by  many  varieties  of  mi 
cro-orgauisms  and  chemical  agents,  but  the  ordinary  pus  cocci  are  the  most 
common  cause  of  the  disease.  Consequently  osteomyelitis  is  not  due  to  a 
specific  poison,  as  was  believed  to  be  the  case  for  a  long  time,  but  it  may  be 
caused  by  any  kind  of  micro-organism  which  excites  acute  inflammation  and 
suppuration.  Acute  infectious  osteomyelitis  is  essentially  a  phlegmon,  so  to 
speak,  of  the  medullary  cavity.  By  transferring  osteomyelitic  pus,  or  the 
above-mentioned  micro-organisms,  to  the  soft  parts,  a  cellulitic  infiammation 
and  suppuration  is  produced.  The  experiments  of  Becker  and  others  show 
that  after  the  introduction  of  pus  cocci  into  the  circulatory  system  or  peri- 
toneal cavity,  typical  acute  osteomyelitis  is  particularly  likely  to  develop  if 
the  affected  bones  have  been  previously  contused  or  broken,  for  the  reason 
that  broken  or  contused  bone  offers  a  favourable  medium  for  the  growth  of 
the  pus  cocci. 

As  Kocher  first  stated,  the  origin  of  acute  infectious  osteomyelitis  is  to  be 
explained  on  the  supposition  that  the  above-mentioned  micro-organisms  enter 
the  circulation  from  some  point  in  the  skin,  or  in  the  lungs  or  intestinal  tract, 
for  example,  particularly  when  at  this  point  there  is  an  inflammation,  such 
as  a  furuncle,  or  even  a  slight  interruption  of  continuity,  and  are  carried  off 
in  the  blood,  from  which  they  are  deposited  in  the  medullary  portion  of  the 
bones  of  youthful  subjects  for  the  anatomical  reasons  mentioned  before;  here 
they  develop,  and  give  rise  to  severe  suppurative  or  gangrenous  inflamma- 
tion with  secondary  involvement  of  the  bone,  periosteum,  and  frequently  the 
joints.  Colzi's  experiments  seem  to  show  that  the  bacteria  in  osteomyelitis 
enter  the  body  most  frequently  from  the  skin,  less  often  from  the  lungs  or 
intestinal  tract.  Inflammations  of  other  organs,  such  as  the  spontaneous 
acute  inflammation  of  the  thyroid  gland  occurring  in  rapidly  growing  goitre, 
originate  in  a  similar  way  from  infection  through  the  blood  (Kocher).  As 
we  remarked  before,  traumatic  lesions  of  bone  favour  the  development  of 
acute  infectious  osteomyelitis.  How  far  catching  cold  conduces  to  its  occur- 
rence is  a  matter  which  cannot  be  determined,  but  the  majority  of  surgeons 
believe  that  it  exerts  some  influence.  Acute  infectious  osteomyelitis  is  also 
occasionally  observed  as  one  of  the  sequela?  of  acute  infectious  diseases 
(measles,  scarlet  fever,  typhoid  fever,  diphtheria),  and  may  follow  suppura- 
tive inflammation  of  various  organs.  It  can  originate  from  an  acute  inflam- 
mation or  collection  of  pus  in  any  organ  of  the  body  if  the  Wrulent  micro- 


(312  INJURIES   AND   SURGICAL   DISEASES  OF   BONE. 

organisms  mentioned  above,  particularly  the  pus  cocci,  are  carried  off  and 
lodged  in  the  man'ow.  Mikulicz  found  the  staphylococcus  pyogenes  aureus 
and  albus  occasionally  in  the  discharges  from  aseptic  wounds  which  healed 
by  ix;rfect  primary  union,  and  Frankel  demonstrated  b<:>th  kinds  of  cocci  in 
the  discharges  accompanying  inflammations  of  the  pharyngeal  cavity,  and 
almost  constantly  in  the  normal  pharynx. 

Anatomical  Changes  in  Acnte  Infectious  Osteomyelitis. — The  anatom- 
ical changes  in  acute  infectious  osteomyelitis  are  in  the  main  the  follow- 
ing :  At  the  outset  there  is  a  diffuse  hypersimia  of  the  medulla,  and, 
later,  yellowish  or  grejish-coloured  foci  of  suppuration  appear  in  it 
which  not  infrequently  coalesce  and  form  a  single  large  collection  of 
pus.  In  the  severest  cases  there  is  observed  a  general  suppuration  of 
the  medulla  of  the  entire  diaphysis — most  commonly  of  the  femur  or 
tibia — with  secondary  collections  of  pus  in  tlie  Haversian  canals,  be- 
tween the  periosteum  and  bone,  in  the  periosteum,  and  in  the  adjoin- 
ing soft  parts.  The  periosteum  probably  becomes  involved  for  the 
most  part  secondarily,  and  is  the  seat  of  an  inflammatory  infiltration 
and  swelling  (serous,  sero-fibrinous  periostitis).  In  this  serous  perios- 
titis the  exudate  is  usually  very  rich  in  albumen,  and  hence  was  called 
by  Oilier  periostitis  albuminosa.  Suppurative  periostitis  only  occurs 
in  the  severer  cases.  As  a  rule,  the  pus  in  acute  infectious  osteomye- 
litis is  rich  in  fat,  in  consequence  of  the  acute  degeneration  of  the  me- 
dullary cells.  Xot  infrequently  the  infectious  matter — the  cocci  and 
the  products  of  their  metabolism — enter  the  circulation,  causing  death 
from  septiciemia  or  pyaemia.  The  supj)urative  separation  of  the  epi- 
physes at  their  junction  with  the  diaphyses  is  a  pathological  change  of 
considerable  importance,  as  well  as  the  secondary'  development  of  in- 
flammations of  the  neighbouring  joints  either  in  the  form  of  a  transi- 
tory mild  serous  or  sero-fibrinous  inflammation,  or  of  a  severe  suppu- 
rative arthritis.  Haaga  states  that  in  four  hundred  aiid  seventy  cases, 
permanent,  slight,  or  pronounced  changes  remained  in  the  joints  one 
hundred  and  eighty -nine  times.  Curvatures  or  angular  deformities  of 
l>ones  sometimes  develop  after  osteomyelitis  (see  page  614).  Xecrosis 
varying  in  amount  even  up  to  total  necrosis  of  an  entire  diaphysis  very 
often  occurs  in  the  diseased  bone.  Acute  infectious  osteomyelitis  ter- 
minates either  in  a  complete  restitutio  ad  integrum,  with  or  withoi^t 
suppuration,  or  in  a  varying  amount  of  necrosis  of  the  bone,  or  in 
death,  particularly  from  pyaemia  and  sej^ticaemia.  Xot  infrequently 
encapsulated  central  bone  abscesses  are  left  behind  which  persist  for 
years. 

Osteomyelitis  occurs  either  in  a  sijigle  bone,  involving  most  com- 
monly the  diaphysis  of  the  long  hollow  bones  (femur,  tibia),  or  as  a 


i<  104.]  ACUTE   IXFLAMMATIONS  OF   BONE.  613 

ninltiple  affection  in  different  bones.  In  the  latter  instance  there  is  a 
simultaneous  infection  of  several  bones,  or  the  primary  disease  in  one 
bone  gives  rise  to  metastases  in  other  bones.  The  shorty  flat  bones 
most  comnioiily  affected  are  the  clavicle,  the  ileum,  and  the  scapula. 
After  total  necrosis  of  the  clavicle  the  bone  may  be  comj)letely  regen- 
erated, its  shape  restored,  and  the  function  of  the  arm  undisturbed. 

Clinical  Course  of  Acute  Infectious  Osteomyelitis. — The  clinical  course 
of  acute  infectious  osteomyelitis  varies  greatly.  The  worst  cases  pre- 
sent the  symptoms  of  a  very  severe  constitutional  disease,  with  high 
fever,  delirium,  rapid  swelling  of  the  affected  bone,  and  death  within 
a  few  days.  In  the  mildest  cases  the  local  and  constitutional  manifes- 
tations are  slight.  The  cases  of  moderate  severity  are  probably  the 
most  common.  The  amount  of  constitutional  infection  does  not  always 
correspond  to  the  extent  of  the  local  disease.  The  fever  in  the  severe 
cases  is,  as  a  rule,  very  higli,  reaching  41°  C.  (104'1°  F.).  The  disease 
generally  begins  with  a  chill  two  to  three  days  after  a  traumatism,  for 
example,  or  exposure  to  cold,  and  during  the  days  immediately  follow- 
ing the  local  disease  can  usually  be  readily  made  out  in  one  bone,  less 
often  in  several  bones.  The  intense  j)ain,  the  even  swelliiig,  the  absence 
at  first  of  any  fluctuation  or  inflammation  of  the  soft  parts,  and  the 
pronounced  disturbance  of  function  are  in  general  characteristic  of  the 
local  disease  of  the  bone.  Many  cases  do  not  begin  so  acutely ;  on  the 
contrary,  they  often  commence  very  gradually.  Occasionally  the  dis- 
ease runs  a  course  which  presents  the  picture  of  an  acute  articular  rheu- 
matism with  inflammation  of  the  large  joints.  In  these  cases  the  osteo- 
myelitis is  always  multiple,  and  the  inflammation  of  the  joints  (secondary 
to  disease  of  the  neighbouring  epiphyses)  often  goes  on  to  suppuration. 

The  subsequent  course  of  acute  infectious  osteomyelitis  is  in  the 
majority  of  instances  favourable.  In  the  mildest  cases  complete  i^esti- 
tutio  ad  integrwrn  takes  place  in  two  to  three  to  four  weeks  without 
any  noticeable  suppuration.  In  the  severest  cases  the  suppuration  of 
the  medulla  runs  a  very  rapid  course,  accompanied  by  secondarj-  sup- 
puration of  the  periosteum  and  phlegmonous  sloughing  of  the  soft  parts, 
sometimes  with  the  evolution  of  gas.  Death  in  such  cases  generally 
occurs  from  what  looks  like  septicaemia  with  severe  typhoid  symptoms, 
or  from  pyaemia  with  secondary  abscesses  in  the  internal  organs.  Prob- 
ably the  most  common  termination  is  recovery,  with  necrosis  correspond- 
ing to  the  amount  of  bone  which  has  been  affected.  The  necrosis  is 
visually  a  central  one — i.  e.,  it  is  limited  to  the  bone  substance  adjoin- 
ing the  medulla.  But  if  there  is  extensive  suppuration  in  the  medulla 
and  periosteum  the  entire  diaphysis  of  a  long  bone  may  die.  Kot  in- 
frequently circumscribed  collections  of  pus  in  the  medullary  cavity  be- 


614  INJURIES  AND   SURGICAL   DISEASES  OP   BOXE. 

come  encapsulated  and  form  abscesses  rnnning  a  chronic  course  with- 
out necrosis,  and  leading  to  a  characteristic  diffuse  thickening  of  the 
affected  bone.  The  suppurative  separation  of  the  epiphyses  is  another 
complication  occurring  in  young  subjects  when  the  suppuration  invades 
these  parts.  The  epiphyseal  separation,  as  in  fractures  or  traumatic 
separations,  is  recognised  by  the  abnormal  mobility.  Usually  there  is 
only  separation  of  one  epiphyses,  which  in  the  femur,  for  example,  is 
the  lower  ;  only  in  I'are  instances  are  both  involved.  The  separation 
of  both  epiphyses  of  a  single  bone  appears  to  have  occurred  most  com- 
monly in  the  tibia. 

The  secondary  inflammations  of  the  joints  which  accompany  acute 
infectious  osteomyelitis  are  either  acute  or  subacute  serous  inflamma- 
tions, or  severe  suppurative  forms,  which  may  even  be  attended  by  the 
evolution  of  gas. 

Sometimes,  after  an  acute  osteomj'elitis  has  run  its  course,  even 
when  no  extensive  necrosis  has  taken  place,  the  bone  may  be  left  ab- 
normally soft.  It  may  lose  its  strength  to  such  an  extent  that  curva- 
ture, angular  deformity,  or  axial  rotation  of  the  diapli3'sis  of  a  bone, 
like  the  femur,  may  be  produced  by  muscular  action  and  by  the  super- 
imposed weight  of  the  body  (Stahl,  Oberst,  and  others).  In  such  cases 
of  curvature  or  deformity  the  bones  involved  are  remarkably  porous, 
and  at  the  point  where  the  disease  is  located  a  fistula  will  generally  be 
found  which  leads  to  a  focus  of  rarefied  bone  with  a  sequestrum. 

As  Krause  has  correctly  stated,  the  osteomyelitic  cocci  appear  to 
possess  great  powers  of  resistance,  since  renewed  formation  of  pus  has 
been  observed  in  old  osteomyelitic  areas  even  after  the  lapse  of  years. 
This  is  the  explanation  for  those  cases  of  multiple  osteomyelitis  in 
which  the  foci  of  the  process  have  apparently  completely"  disappeared, 
but  in  which,  nevertheless,  suppuration  and  necrosis  subsequently  de- 
velop. 

Diagnosis  and  Prognosis  of  Acute  Osteomyelitis. — The  diagnosis  of 
acute  infectious  osteomyelitis  can  be  made  from  what  has  been  stated 
about  the  anatomical  changes  and  the  symptomatology. 

The  prognosis,  in  the  majority  of  cases,  is  favourable  quoad  mtam. 
But  it  must  be  borne  in  mind  that  the  disease  may  cause  death  at  any 
stage,'SO  long  as  an  escape  is  not  provided  for  the  pus  by  chiselling 
open  the  medullary  cavity.  Many  cases,  especiallj-  those  caused  by  the 
streptococcus,  run  a  rapidly  fatal  course.  After  the  suppuration  has 
subsided,  it  is  mainly  the  extent  of  the  necrosis,  the  amount  of  inflam- 
mation which  has  occurred  in  the  joints,  the  condition  of  the  epiphyses, 
etc.,  which  determine  the  character  of  the  case. 

The  Treatment  of  Acute  Infectious  Osteomyelitis. — The  treatment  of 


§  104.J  ACUTE  INFLAMMATIONS  OP  BONE.  615 

acute  primary  osteomyelitis  lias  n^ained  in  efficacy  with  our  knowledge 
of  tlie  etiology  of  the  disease.  In  the  treatment,  a  distinction  must  he 
made  hetween  the  severe  cases,  which  run  a  very  acute  course,  and 
those  which  are  mild  and  suhacute.  In  the  severest  cases  with  high 
fever,  a  means  of  escape  should  be  provided  for  the  inni  as  soon  as 
possible  by  making,  under  antiseptic  i)recautions,  a  long  incision  down 
to  the  bone,  at  the  point  of  greatest  tenderness,  or  where  the  perios- 
teum is  swollen,  and  then  cutting  with  the  hammer  and  chisel  a  large 
enough  opening  into  the  medullary  cavity  in  the  shape  of  a  gutter. 
If  operative  measures  are  adopted  .early  enough,  the  otherwise  un- 
avoidable necrosis  of  the  bone  and  the  breaking  through  of  pus  into  a 
neighbouring  joint  may  sometimes  be  prevented,  and  the  course  of  the 
disease  will  thus  be  rendered  milder  and  shorter  than  it  otherwise 
would  be.  To  avoid  recurrences  and  to  obtain  speedy  recovery,  it  will 
often  be  found  a  better  plan,  instead  of  making  a  gutter-shaped  open- 
ing into  the  medullary  cavity  of  a  long,  hollow  bone,  to  remove  all  of 
the  bone  except  a  wall  of  cortex  (Riedel).  This  early  scraping  out  of 
the  infected  medulla  has  recently  been  energetically  supported  by 
Tscherning  (Copenhagen),  Thelen,  and  others,  and  is  in  every  respect 
a  rational  procedure,  when  it  is  remembered  that  we  have  to  deal 
essentially  with  a  cellulitis  of  the  medulla ;  and  in  the  case  of  any 
cellulitis  it  should  be  our  aim  to  evacuate  the  pus  at  the  earliest  pos- 
sible moment.  It  is  not  always  easy  to  decide  in  what  cases  the  aseptic 
opening  of  the  diseased  bone  with  the  chisel  should  be  attempted  ; 
moreover,  many  cases  run  such  a  rapidly  fatal  course  that  the  correct 
diagnosis  cannot  be  made  at  an  early  enough  period.  The  evacuation 
of  pus  from  bones,  such  as  those  of  the  pelvis,  is  difficult,  and  I  have 
seen  very  severe  cases  involving  just  these  bones  where  death  occurred 
quickly.  After  opening  the  medullary  cavity  of  a  long  hollow  bone,, 
the  suppurative  focus  should  be  scraped  out,  and,  if  necessary,  the  en- 
tire medullary  cavity.  The  periosteum  and  soft  parts  should  likewise 
be  carefully  examined  for  the  presence  of  pus,  and,  if  found,  it  should  be 
let  out  by  incision  and  drainage.  Finally,  the  medullary  cavity  should 
be  disinfected  as  carefully  as  possible  with  a  one-tenth-per-cent.  solution 
of  bichloride  of  mercury  or  a  three-per-cent.  solution  of  carbolic  acid, 
and  then  filled  with  iodoform  gauze,  over  which  is  placed  an  antiseptic 
protective  dressing.  Permanent  antiseptic  irrigation  (see  page  178) 
can  be  used  with  advantage  for  severe  cases,  instead  of  the  antiseptic 
protective  dressing.  Immobilisation  of  the  extremity  in  the  best  pos- 
sible position  by  splints,  etc.,  cannot  be  emphasised  too  strongly.  Un- 
fortunately, in  spite  of  energetic  and  eaidy  operative  local  treatment, 
some  of  the  severe  cases  will  die  in  consequence  of  the  systemic  intoxi- 


616  INJURIES   AXD  SURGICAL  DISEASES  OF  BONE. 

cation  already  present,  which  even  an  amputation  or  a  total  subperios- 
teal resection  of  the  diseased  bone  will  not  always  prevent.  Complete 
resection  of  the  bone — i.  e.,  the  removal  of  the  diseased  bone  in  toto — 
seems  to  me  very  inadvisable,  as  its  efficacy  has  as  yet  not  been  suffi- 
ciently established.  Amputation  in  the  acute  stage  is  rarely  indicated, 
though  it  may  be  in  the  later  stages,  when  suppuration  becomes  so 
excessive  as  to  tlireaten  to  carry  off  the  patient  from  exhaustion. 

In  the  moderately  severe  and  the  mild  cases  the  local  treatment  con- 
sists in  the  energetic  application  of  ice,  in  placing  the  extremity  in  an 
elevated  position,  and  in  immobilising  it  as  much  as  possible  with  a 
splint.  Others  prefer  moist  heat  to  ice  for  alleviating  the  pain.  I  con- 
sider that  the  application  of  iodine,  which  was  formerly  so  much  used, 
has  but  little  effect.  If  there  is  marked  swelling  of  the  periosteum  and 
the  pain  due  to  this  is  severe,  even  though  no  pus  can  be  obtained  by 
a  test  puncture,  I  nevertheless  advocate  early  incisions  to  lessen  the  ten- 
sion, and  thus  ease  the  patient's  pain.  Furthermore,  it  is  possible  by 
this  means  to  prevent,  or  at  any  rate  to  lessen,  a  subsequent  necrosis  of 
the  bone.  Not  infrequently  cases  which  were  at  the  outset  mild,  be- 
come so  severe  that  it  may  be  necessary  to  chisel  a  groove  into  the 
medullary  cavity  and  drain  or  pack  the  latter  with  iodoform  gauze. 

As  regards  the  treatment  of  complications  the  following  should  be 
noted  :  Inflammations  of  joints  are  treated  according  to  the  general 
principles  applicable  to  these  affections  (see  Diseases  of  Joints).  If  sup- 
puration occurs,  the  joint  should  be  opened  and  drained  as  soon  as  pos- 
sible. Separations  of  the  epiphyses  are  treated  in  the  same  way  as  a 
fracture.  Curvatures  of  bone  following  osteomyelitis  can  sometimes 
be  overcome,  after  scraping  out  the  osteomyelitic  focus  and  removing 
the  sequestrum  which  may  be  present,  by  extension  with  a  heavy  M-eight 
(five  to  ten  kilogrammes).  The  treatment  of  the  necrosis  which  is  so 
common  a  result  of  osteomyelitis  is  described  in  §  106. 

Amputation  accompanied  by  Scraping  out  the  Bone  Stump. — Perkowsky 
practised  amputation  in  eight  severe  cases  of  osteomyelitis,  aud  then  scraped 
out  the  medullary  cavity  of  the  diseased  bone  stump,  removing  in  three  cases 
the  medulla  of  the  entire  stump  with  the  sharp  spoon,  so  that  only  a  thin 
shell  of  bone  was  left.  Necrosis  did  not  take  place  in  a  single  case,  and  a 
rapid  recovery  followed  in  all  eight  cases  under  iodoform  dressings.  Per- 
kowsky thus  avoided  disarticulation  or  amputation  of  the  limb  at  a  higher 
point. 

The  treatment  of  acute  periostitis  occurring  by  itself  is  conducted 
according  to  the  general  rules  which  apply  to  inflammation.  If  the  acute 
periostitis  is  suppurative,  incision  is  employed  ;  if  not  suppurative,  anti- 
phlogesis. 


j  104.J  ACUTE  INFLAMMATIONS  OF  BONE.  617 

The  Acute  Traumatic  Inflammations  of  the  Periosteum  and  Medulla. — 

Acute  traiiiiiatic*  iiillaimnatiuns  of  the  j)eriosteiiiii  and  medulla  are  ol)- 
served  after  injuries  of  various  kinds,  such  as  contusions,  wounds  of  the 
periosteum,  subcutaneous  ai\d  compound  fractures,  wounds  of  bone,  etc. 
Acute  non-suppurative  periostitis  and  osteomyelitis  traumatica  take  place 
after  every  contusion  and  subcutaneous  fracture.  The  su})purative 
form  is  always  caused  by  infection  with  bacteria  which  enter  through 
some  wound  or  circulate  in  the  blood.  This  includes,  moreover,  the 
acute  osteomyelitis  of  the  amputation  stump  which,  especially  in  the 
days  before  antisepsis,  terminated  in  death  from  pyaemia.  At  present 
we  have  learned  to  avoid  this  form  of  osteomyelitis  with  certainty  in 
our  amputations  by  employing  antisepsis  and  asepsis.  The  anatomical 
changes  and  the  cause  of  the  acute  (traumatic)  periostitis  and  osteomye- 
litis are  essentially  the  same  as  in  the  above-described  spontaneous  acute 
infectious  osteomyelitis  and  pwiostitis. 

Metastatic  Inflammations  of  Bone. — The  metastatic  inflammations  of 
bone  in  pyaemia,  typhoid  and  scarlet  fevers,  measles,  small-pox,  etc.,  are 
either  analogous  to  the  spontaneous  acute  infectious  osteomyelitis  and 
periostitis,  or  they  run  a  chronic  course  with  the  formation  of  circum- 
scribed cold  abscesses.  The  inflammations  of  bone  occurring  in  the 
course  of  typhoid  fever  are  mainly  observed  in  the  ribs,  where  they  be- 
come localised  as  a  chondritis  or  perichondritis,  having  a  very  chronic 
course  ;  typhoid  bacilli  have  repeatedly  been  demonstrated  in  the  in- 
flammatory foci  (Bergmann,  Potter,  etc.).  In  the  cases  of  metastatic 
bone  inflammation  from  plugging  of  the  vessels  by  emboli,  a  corre- 
sponding necrosis  of  bone  occurs  which  is  called  an  "  embolic  necrosis." 
Such  embolic  necroses  from  obstruction  to  the  aft'erent  flow  of  blood 
are  occasionally  observed  in  endocarditic  processes,  when  blood-clots 
with  or  without  micro-organisms  break  loose  from  the  growths  on  the 
endocardium  and  are  swept  away  and  lodge  in  the  bones.  Epiphyseal 
separations  and  secondary  joint  diseases,  which  were  described  above, 
may  also  accompany  metastatic  periostitis  and  osteomyelitis. 

Growth.  Fever. — In  young'  subjects  there  is  occasionally  obser^^ed  a  marked 
temporary  tenderness  to  pressure  in  the  epiphyses  of  the  long-  bones,  espe- 
cially the  femur,  humerus,  aud  tibia,  accompanied  by  inflammatory  irritation 
of  the  neighbouring  joints,  with  the  manifestations  of  fever  and  a  correspond- 
ing disturbance  of  the  general  health.  Bouilly  aud  Juillier  have  designated 
this  condition  as  growth  fever.  It  is  a  question  whether  in  such  cases  there 
may  not  sometimes  be  present  a  true  acute  infectious  osteomyelitis  of  the  mild- 
est kind,  which  terminates  in  i-esfitufio  ad  integrum. 

Embolic  Foreign-Body  Inflammations  of  Bone. — Great  interest  attaches 
to  the  embolic  foreign-body  inflannnations  of  bone  which  are  observed 


618  INJURIES  AND  SURGICAL  DISEASES   OF   BONE. 

in  motlier-of-pearl  turners  and  workers  in  woollen  and  jute  mills.  Peo- 
ple employed  in  these  occupations  breathe  in  the  particles  of  mother- 
of-pearl  dust,  wool,  or  jute,  which  then  pass  from  the  lungs  into  the 
circulation  and  lodge  in  the  small  arteries  of  the  medullary  portion  of 
the  bones,  particularly  the  terminal  arteries  at  the  extremities  of  the 
diaphysis,  and  here  excite  embolic  inflammation  of  the  medulla  with 
secondary  involvement  of  the  periosteum.  As  is  the  case  with  acute 
infectious  osteomyelitis  and  periostitis,  youthful  individuals  are  the 
ones  who  are  principally  affected  by  these  inflammations  of  the  me- 
dulla in  the  diaphyseal  ends  of  the  bones  and  in  the  epiphyses. 
Gussenbaur,  Englisch  and  Levy  have  given  accurate  descriptions  of 
the  inflammations  of  bone  to  which  mother-of-pearl  turners  are  sub- 
ject. The  sj'mptoms  consist  in  very  painful  swellings,  which  usually 
appear  suddenly  at  the  ends  of  the  diaphyses  with  marked  swelling  of 
the  periosteum.  The  course  of  the  affection  is  generally  subacute,  and 
suppuration  has  as  yet  never  been  observed.  Restitutio  ad  inteyrinn 
ordinarily  follows,  the  worst  that  happens  being  a  thickening  of  the 
periosteum,  which  persists  for  a  greater  or  less  length  of  time.  But  if 
the  turners  resume  their  occupation,  recurrences  of  the  inflammation 
are  frequently  observed,  which  run  a  chronic  course,  with  thickening 
of  the  spongy  bones  of  the  carpus  or  tarsus,  or  of  the  diaphyseal  ends 
of  the  long  bones. 

Klein  has  described  the  bone  disease  of  jute  spinners.  In  this,  too, 
there  is  an  inflammation  of  the  medulla  and  periosteum  in  the  region 
of  the  epiphyseal  cartilages,  accompanied  by  severe  pain.  A  consid- 
erable growth  of  epiphyseal  cartilage  usually  takes  place,  giving  rise  to 
secondary  curvature  of  the  bones,  particularly  the  tibia.  In  this  affec- 
tion also  suppuration  or  necrosis  never  occurs.  V 

'  §  105.  The  Chronic  Inflammations  of  Bone  (Chronic  Periostitis,  Os- 
titis, and  Osteomyelitis). — The  most  important  chronic  diseases  of  bone 
are 'the  mycotic,  of  which  the  tubercular,  syphilitic  and  actinomycotic 
inflammations  of  bone  are  prominent  examples.  Furthermore,  acute 
infectious  diseases,  such  as  nieasles,  scarlatina,  typhoid  fever,  etc.,  rna}- 
be  followed  not  only  by  acute  inflammations  of  bone,'  as  mentioned 
above,  but  also  by  inflammations  which  are  at  first  latent,  and  then 
subsequently  manifest  themselves  as  affections  running  a  chronic  course. 
,  (\.  The  chronic  inflammation  of  the  ribs  which  follows  typhoid  fever  is 
an  example  of  this  class  of  cases  (see  page  617).  '  The  other  chronic  in- 
flammations of  bone  are  mostly  secondary  to  preceding  acute  inflam- 
mations, and  include,  as  a  terminal  stage  of  the  latter,  necrosis.  Chronic 
inflammations  of  bone  are  also  sometimes  the  result  of  the  extension 
to  the  latter  of  chronic  inflammation  in  the  surrounding  parts.     The 


§105.]  THE  CHRONIC  INFLAMMATIONS  OF  BONE.  619 

changes  wliicli  occur  in  bone  in  consequence  of  chronic  inflammation 
consist  either  in  a  destruction  of  the  bone  sul)stance  (caries,  necrosis) 
or'^in  a  reactive  new  formation  of  bone.' 

Chronic  Periostitis. — Amongst  the  various  forms  of  chronic  perios- 
titis, mention  should  lirst  be  made  of  the  periostitis  clironica  fibrosa. 
In  this  variety  tough,  fibrous  thickenings  of  the  periosteum  develop, 
sometimes^ with  absorption  of  the  superficial  portions  of  the  bone  (caries 
snperficialis),  and  sometimes  with  new  formation  of  bone.  In  the  latter 
instance  the  process  is  an  ossifying  periostitis. 

Periostitis  Albuminosa  or  Mucinosa  (Non-purulenta).— Poncet  and  Oilier 
were  the  ftrst  to  describe  a  peculiar  form  of  periostitis  under  the  name  of 
periostitis  albuminosa  (ganglion  periostale),  concerning  the  nature  of  which 
different  authorities  hold  very  divergent  views.  The  affection  attacks  almost 
exclusively  the  ends  of  the  diaphysis  of  the  long,  hollow  bones  in  young  sub- 
jects from  fifteen  to  twenty  years  of  age,  and  involves  not  only  the  periosteum 
but  frequently  the  bone  also  (ostitis  albuminosa).  Schlange  has  proposed 
calling  it  periostitis  and  ostitis  non-purulenta,  and  Riedinger  periostitis  mu- 
cinosa. As  a  rule,  the  disease  begins  with  severe  pain,  swelling  at  the  lower 
end  of  the  diaphysis  in  the  neighbourhood  of  the  epiphyseal  line,  and  fever, 
as  is  the  case  in  acute  primary  osteomyelitis.  After  a  few  days  the  fever  and 
pain  disappear,  and  the  swelling  of  the  j)eriosteum  and  bone  becomes  more 
and  more  prominent.  There  will  be  found  at  the  diseased  point,  instead  of 
pus.  either  a  bloody  serous  or  a  hydrocele-  or  synovial-like  fluid  which  has 
the  consistency  of  tenacious  mucus.  The  fluid  lies  either  beneath  the  peri- 
osteum, or  within  it  in  the  form  of  a  cyst,  or  on  its  outer  surface,  and  in  the 
latter  instance  there  is  also  a  diffuse  oedematous  swelling  of  the  surround- 
ing soft  parts.  The  periostitis  and  ostitis  albuminosa,  or  non-purulenta,  or 
mucinosa,  is  not  tubercular  in  its  nature,  but  is  possibly  a  non-suppurative 
osteomyelitis  and  periostitis  caused  by  weakened,  attenuated  pus  cocci;  it 
resembles  an  inflammation  which  has  not  passed  beyond  the  serous  stage. 
Pus  cocci,  including  the  staphylococcus  pyogenes  albus  and  also  the  aureus, 
have  been  repeatedly  demonstrated  in  periostitis  albuminosa.  Vollert  states 
that  a  mucoid  metamorphosis  of  the  leucocytes  takes  place  in  this  affection. 


'.3?'  y  .A 


Fig.  348. — Osteopliyte  (Patholmrical  miiscnni  at  Lcipsic). 


Its  course  is  very  chronic,  and  necrosis  of  the  bone  is  often  present.     The 
disease  is  very  rebellious  to  therapeutic  measures,  and  recurrences  frequently 


620 


INJURIES   AND   SURGICAL   DISEASES   OF   BONE. 


take  place,  or  fistulae  may  persist  for  months  or  years.     The  hest  treatment 
consists  in  incision  and  energetic  scraping  out  of  the  underlying  diseased 

bone,  with  or  without  chiselling  an  open- 
ing into  the  medullary  cavity.  Cystic 
formations  should  be  careful!}'  extir- 
l^ated. 

In  the  periostitis  clironica  ossifi- 
cans the  new  formation  of  bone  is 
either  limited  to  a  circumscribed  por- 
tion of  the  bone,  giving  rise  to  what 
is  called  an  osteophyte  (Fig.  348),  or 
diffuse  hypertrophies — Iwperostoses, 
as  tliey  are  called — are  developed,  in 
consequence  of  which  thickenings  of 
the  bone  resembling  elephantiasis  re- 
sult (Fig.  34:9).       . 

In  addition  to  chronic  fibrous  and 
chronic  ossifying  periostitis,  we  rec- 
ognise a  chronic  suppurative  perios- 
this,  which  sometimes  is  the  terminal 
stage  of  an  acute  periostitis  and  some- 
times develops  gradually  as  a  disease 
b}'  itself,  and  chiefly  comes  into  con- 
sideration as  a  concomitant  phenom- 
enon of  necrosis  or  caries  of  bone. 
In  chronic  suppurative  periostitis  we 
have  to  deal,  for  the  most  part,  with 
specific  processes,  such  as  tuberculo- 
sis, syphilis,  or  actinomycosis,  and  also  with  necrosis  of  bone  from  vari- 
ous causes.  Tubercular  periostitis  is  either  primary  or  secondary  to 
tuberculosis  of  bone  or  its  medulla,  or  of  the  surrouiiding  soft  parts. 

Treatment  of  Chronic  Periostitis. — Chronic  non-sujjpurative  perios- 
titis should  be  treated  briefly  as  follows :  First  of  all  its  cause  should 
be  determined  and  proper  steps  taken  to  remedy  it.  '''  To  relieve  the 
tension,  pain,  and  local  inflammatory  symptoms,  incisions  and  hydro- 
pathic applications  can  be  used  with  advantage.  It  is  also  an  excellent 
plan  to  paint  the  parts  with  tinct.  iodi  fortior  alcoh.  (five  parts  iod. 
pur.  to  30*0  of  alcohol).  '^Compression  by  the  elastic  bandage  is  of  use 
for  the  fibrous  thickening  and  osteophytes  ^but  troublesome  osteophytes, 
occurring,  for  example,  in  connection  with  an  ulcer  of  the  leg  or  some 
other  disease  of  the  soft  parts,  should  be  removed  with  the  hammer 
and  chisel. 


fiG.  S49. — Hyperostosis  (elephantiasis)  of 
the  femur  (Pathological  museum  at 
Leipsie). 


^105.]  THE   CHRONIC   INFLAMMATIONS   OF   BONE.  021 

The  treatment  of  chronic  suppurative  periostitis  is  likewise  mainly 
determined  by  the  cause,  and  we  shall  discuss  this  disease  more  fully 
under  Tuberculosis,  Caries,  and  Necrosis,  etc.  (see  also  Syphilis,  §  84, 
and  pnijc  <)t^(^). 

Tuberculosis  of  Bone. — One  of  the  most  important  and  by  far  the 
most  common  of  chronic  bone  diseases  is  tuberculosis  (ostitis  tubercu- 
losa, caries  tuberculosa  or  fungosa),  which  occurs  chiefly  as  tubercular 
periostitis  and  osteonn'clitis,  and  leads  to  extensive  destruction  of  bone 
— to  caries,  as  it  is  called  (Fig.  350) — and  to  necrosis.  Volkmann  in 
]>articular  has  won  lasting  honours  by  his  studies  upon  the  subject  of 
tuberculosis  of  bones  and  joints,  and  Robert  Koch  has  gi'eatly  advanced 
our  knowledge  upon  the  etiology  of  tubercular  inflammation  by  demon- 
strating and  obtaining  in  pure  cultures  the  tubercle  bacillus  (§  83). 
We  now  know  that  all  those  forms  of  inflannnation  which  affect  bone, 
and  have  been  designated  as  caries,  spina  ventosa,  scrofulous  or  fun- 
goiis  inflammation  of  bones  and  joints,  tumor  albus,  etc.,  are  in  the 
main  true  tubercular  inflammations. 

Tubercular  inflammation  of  bone  occurs  most  commonly  in  young 
individuals — i.  e.,  in  growing  bone — for  the  reason  mentioned  before, 
namely,  that  the  formed  foreign  elements  circulating  in  the  blood,  par- 
ticularly the  tubercle  bacilli,  are  more  readily  deposited  in  the  branches 
of  the  vessels  in  growing  bone,  although  tuberculosis  also  occurs  dur- 
ing the  later  years  of  life,  and  may  be  met  with  even  in  extreme  old 
age.  The  poison  of  tuberculosis,  the  tubercle  bacilli,  are  generally 
carried  to  the  bones  by  means  of  the  blood-vessels,  as  can  be  easily 
proved  by  experiments  on  animals.  Traumatic  injuries  of  bone,  as 
we  remarked  before,  favour  the  development  of  tuberculosis.  Tuber- 
culosis of  bone  may,  moreover,  be  due  to  the  direct  extension  to  the 
latter  of  a  tubercular  process  in  the  surrounding  tissues,  such  as  the 
skin,  subcutaneous  tissue,  tendon  sheaths,  synovial  membrane,  etc. 
Tubercular  inflammations  of  the  vertebrse  and  of  the  bones  of  the 
hands  and  feet  are  the  most  common. 

Anatomical  Changes  in  Tuberculosis  of  Bone.— Tuberculosis  of  bone 
almost  always  begins  with  the  formation  of  circumscribed  foci'in  the 
periosteum,  in  the  epiphyses  of  the  long  bones,  or  in  the  medulla, 
particularly  in  the  spongiosa  of  the  short  bones  (Fig.  351);  less  com- 
monly the  disease  is  more  diffuse.  The  tubercular  focus  often  remains 
for  a  long  time  the  size  of  a  pea  or  a  hazel-nut,  and  then  enlarges  by 
direct  extension  from  its  edges  or 'by  the  development  of  new  foci  in 
the  region  surrounding  the  primary  one.  The  individual  foci  then 
coalesce,  and  thus  large  tubercular  foci  or  diffuse  processes  originate. 
Not  infrequently  several  distinct  foci  are  observed  in  one  and  the  same 


622 


INJURIES   AND   SURGICAL   DISEASES  OF  BONE. 


% 


bone,  or  tubercular  iiiflammations  occur  in  different  bones  at  the  same 
time  or  one  after  the  other.  The  tubercular  focus  is  made  up  of  the 
characteristic  tubercles  which  originate  from  the  lodgement  and 
growth  of  the  tubercle  bacilli,  and  have  been  minutely  described  on 
page  408.  Wherever  a  tubercular  focus  develops  in  bone  (Fig.  351), 
caries  results — i.  e.,  the  bone  disappears  in  the  form  of  lacunar  absorp- 
tion (see  Fig.  343) — while  the  focus  itself  sooner  or  later  becomes 
the  seat  of  a  cheesj  degeneration  beginning  in  its  centre.  If  the 
bone  has  not  been  destroyed  at  the  time  that  caseation  of  the  tuber- 
cular focus  occurs,  mortification  of  the  bone  then  takes  place  in  toto — 
i.  e.,  a  so-called  tubercular  serjuestrum  forms  which  becomes  sepa- 
rated from  the  surrounding  parts  by  a  demarcating  suppuration.  In 
the  later  stages  the  tubercular  sequestrum  lies  completely  free  in  a 
cavity  of  greater  or  less  size,  containing  cheesy,  riocculeni  ]^us,  with  or 


<''-. 

'Z/^- 


K 


-Tu 


Fig.  351.— Fungous  granulations  with  tubercles 
(  Tu)  in  the  oancellous  portion  of  the  talus  : 
A',  intact  trabecula  of  bone. 


Fig.  3.50. — Tubereulo.^is  of  the  lower  epi- 
physis of  th(^  femur,  with  two  seques- 
tra {(i).  Tlie  process  has  broken 
through  into  the  knee-joint  ( Weber j. 

without  fistulae  opening  externally  (Fig.  350).     In  general  the  charac- 
teristic tubercular  sequestrum  is  a  larger  or  smaller  caseated  concretion 
of  bone  through  which  has  grown  tubercular  or  caseous  granulation 
tissue.     Very  often  the  entire  tubercular  focus  becomes  softened  and  ^ 
liquefied  in  toto  without  the  formation  of  a  sequestrum.     The  central  j^^ 
abscesses  of  bone,  which  exist  for  years,  are  partly  due  to  tubercular  | 
processes,  partly  to  a  preceding  primary  acute  infectious  osteomje- 
litis,  and  partly  to  metastasis  in  the  course  of  acute  infectious  diseases. 
A  reactive  deposit  of  bone  often  takes  place  around  the  tubercular 
focus  in  the  bone  or  its  medulla,  causing  it  to  become  more  or  less 
completely  enclosed  by  thickened,  sclerotic  bone  tissue.     In  the  pro- 
nounced cases  of  sclerosis  of  bone  the  bony  structure  becomes  as  dense 


§105.]  THE  CHRONIC   INFLAMMATIONS  OF   BONE.  623 

as  ivory  (so-called  ebnrnatio  ossis),  and  the  medullary  cavity  may  be 
completely  obliterated.  But  in  other  instances  all  traces  of  reactive 
hyperplasia  of  bone  are  absent,  even  though  the  tubercular  intianuna- 
tion  lias  existed  for  years. 

In  the  tuberculosis  of  bone  there  are  also  formed  sacculated  collec- 
tions of  pus — cold  abscesses — which  are  enclosed  in  a  characteristic 
so-called  pyogenic  membrane  consisting  of  connective  tissue  and  granu- 
lation tissue  containing  tubercles.  The  abscesses  either  rupture  exter- 
nally in  the  region  whei-e  they  originated,  or  the  force  of  gravity  causes 
them  to  sink  lower.  In  the  case  of  tubercular  inflammation  of  the 
cervical  and  thoracic  vertebrne,  for  example,  they  descend  along  the 
anterior  surface  of  the  vertebrae,  following  the  course  of  the  psoas 
muscle,  and  appear  beneath  Poupart's  ligament  (so-called  congestion 
abscesses).  These  congestion  abscesses  extend  in  a  perfectly  typical 
manner,  which  is  governed  by  the  anatomical  conditions — i.  e.,  they 
follow  the  natural  spaces  between  the  tissues  corresponding  to  the  ar- 
rangement of  the  fasciae  and  aponeuroses. 

The  caries  which  accompanies  tuberculosis  is  often — in  the  case  of 
the  vertebris,  for  example — very  considerable.  In  consequence  of  this 
there  develops  in  the  back  the  so-called  kyphosis  or  Pott's  hump,  named 
after  the  English  surgeon  Percival  Pott,  who  first  described  this  disease. 
Marked  destructive  changes  also  take  place  in  the  small  bones  and  articu- 
lar ends  of  the  long  ones,  leading  to  deformities  of  various  kinds,  with 
subluxations  and  complete  dislocations  of  the  deformed  articular  extremi- 
ties of  the  bones.  In  the  fingers  and  toes  tuberculosis  usually  occurs  as 
a  tubercular  osteomyelitis,  with  a  spindle-shaped  enlargement  of  the  bone 
{spiyia  ventosa).  In  this  condition  the  cortex  of  the  bone  becomes  con- 
stantly thinner  in  consequence  of  the  tubercular  osteomyelitis,  while 
at  the  same  time,  as  a  result  of  the  reactive  periostitis,  osteophytes  are 
formed.  Spina  ventosa  often  heals  without  suppuration  or  necrosis 
having  taken  place,  and  with  a  spontaneous  and  complete  restitutio  ad 
integrum.  The  same  form  of  tuberculosis  also  occurs  in  the  long 
bones,  such  as  the  tibia  and  femur. 

The  most  common  site  of  bone  tuberculosis  in  the  long,  hollow 
bones,  whether  located  in  the  periosteum  or  in  the  interior  of  the  bone, 
is  in  the  region  of  the  epiphyses.  This  is  the  reason  why  secondary 
tuberculosis  of  the  joints  is  so  common  (see  §  114,  Tuberculosis  of 
Joints).  Tuberculosis  of  the  diaphysis  of  a  bone  is  comparatively  rare 
— a  fact  of  great  diagnostic  importance,  especially  in  the  case  of  adults. 
Consequently,  if  the  shaft  of  a  bone  is  diseased,  particularly  in  an  adult, 
we  think  of  syphilitic  or  some  other  bone  disease  before  tuberculosis. 

As  regards  other  bones,  tuberculosis  is  especially  common  in  the 


624  INJURIES  AND  SURGICAL   DISEASES  OP   BONE. 

bones  of  the  sknll^  in  the  orbital  portion  of  the  snjierior  maxilhi,  in  the 
ribs,  and  particularly  in  the  spiiial_ column  and  the  bones  of  the  carpus 
and  tarsus. 

Under  the  microscope,  tuberculosis  of  bone  presents  a  picture  which 
corresponds  to  the  tubercular  inflammation  described  in  §  83.  Koch's 
tubercle  bacilli  will  be  found  most  abundantly  where  the  tubercular  pro- 
cess is  beginning,  the  best  method  of  staining  being  that  of  Ehrlich's, 
with  fuchsin  or  gentian  violet.  Nevertheless,  their  demonstration  in 
tuberculosis  of  bone  is  sometimes  very  difiicult,  or  even  impossible — a 
fact  which  has  been  commented  upon  before.  In  tuberculosis  of  bones 
and  joints  Miiller  frequently  found  peculiar  bodies  resembling  fat 
dr(»ps,  which  not  uncommonly  were  surrounded  l)y  minute  granules, 
and,  like  these,  were  characterised  by  taking  on  a  deep  red  or  violet 
stain.     These  bodies  probably  bear  some  relationship  to  the  bacilli. 

The  Clinical  Course  of  Bone  Tuberculosis. — The  clinical  course  of 
tuberculosis  of  bone  is  usually  very  chronic.  There  are  often  symp- 
toms of  tuberculosis  in  other  organs — the  lungs,  for  instance — at  the 
same  time.  Heredity  is  important — i.  e.,  tuberculosis  of  the  parents  or 
grandparents  or  other  near  relatives.  Quite  often  it  happens  that  for 
a  long  time  symptoms  peculiar  to  tuberculosis  of  bone  are  absent ;  severe 
pain  especially  may  long  be  missed,  unless  a  neighbouring  joint,  the  peri- 
osteum, or  overlying  parts  are  attacked  by  the  tubercular  inflammation. 
In  the  majority  of  instances  the  symptoms  pointing  to  tubercular  in- 
flammation will  not  make  their  appearance  till  after  the  disease  has 
existed  for  months,  the  development  of  an  appreciable  tumour,  par- 
ticularly if  the  tuberculosis  is  periosteal,  being  the  first  intimation  of 
the  process.  But  even  if  the  tuberculosis  is  located  in  the  bone  or 
medullary  cavity,  an  appreciable  tumour  will  sometimes  be  formed  after 
several  months  in  consequence  of  a  thickening  of  the  bone,  while  in 
other  instances,  though  the  tuberculosis  may  have  existed  for  3-ears,  all 
swelling  will  be  absent.  Under  these  conditions  the  diagnosis  can  often 
only  be  made  when  the  periosteum  begins  to  become  involved  in  the 
inflammation,  and  there  is  tenderness  on  pressure  over  the  area  in  ques- 
tion, or  when  a?dema  of  the  skin  is  present.  As  the  tuberculosis  ad- 
vances the  symptoms  become  more  pronounced,  especially  the  swelling 
at  the  diseased  spot,  the  pain,  particularly  if  the  tuberculosis  is  located 
in  the  medulla,  the  disturbance  of  function,  the  development  of  fistulse, 
burrowing  of  pus,  etc.  The  disturbance  of  function  is  most  pronounced 
in  tuberculosis  of  the  epiphysis  in  the  neighbourhood  of  a  large  joint 
like  the  hip  or  knee.  The  tumefaction  accompanying  tubercular  infil- 
tration of  the  periosteum  or  medulla  is  either  due  to  osteophyte  forma- 
tion, or  the  bone  is  puffed  out,  as  it  were,  by  tubercular  osteomyelitis, 


§  105.]  THE   CORONIC   INFLAMMATIONS   OP   BOXE.  625 

in  the  manner  wliich  we  described  as  occurring  in  spina  ventosa  of  tlie 
phalanges  of  the  fingers.  In  this  spina  ventosa  of  the  fingers  the  bone 
may  feel  firm,  or  elastic  and  thin.  After  a  certain  length  of  time  the 
tubercular  pus  works  its  way  outwards  and  breaks  spontaneously 
through  the  skin,  and  the  thin  li(]uid,  usually  mixed  with  cheesy  floc- 
culi,  is  discharged.  Fistulous  ulcers  with  a  cheesy  base  and  under- 
mined edges  then  develop  from  the  fistuhe.  If  a  })robe  is  passed 
through  the  fistula  it  either  immediately  comes  in  contact  with  the 
bone,  or  penetrates  into  the  medullary  cavity.  The  other  secondary 
manifestations  of  tuberculosis,  the  cold  or  congestion  abscesses,  etc., 
have  been  sufficiently  described,  and  we  need  only  call  attention  to  the 
fact  that  the  latter  do  not  heal  up  until  the  original  focus  which  gave 
rise  to  them  has  disappeared.  Their  course  is  usually  very  tedious, 
especially  in  the  case  of  tubercular  inflammation  of  the  spine.  The 
tubercular  inflammations  of  joints  are  discussed  in  §  114.  A  tubercular 
deposit  in  the  periosteum  or  medulla  of  an  epiphysis,  lying  in  imme- 
diate proximity  to  a  joint,  often  works  its  way  to  the  surface  extra- 
articularly ^  and  leaves  the  joint  intact. 

The  general  health  in  tuberculosis  of  bone  is  very  often  but  little 
or  not  at  all  affected.  There  is  frequently  a  slight  fever,  varying  with 
the  extent  of  the  process.  It  is  a  common  occurrence  to  find  that  the 
general  health  is  only  slightly  disturbed  even  when  extensive  multiple 
tuberculosis  is  present.  In  general  the  fever  is  most  pronounced  before 
the  tubercular  inflammation  has  extended  beyond  the  bone,  but  it  is 
usually  slight,  and,  as  a  rule,  disappears  more  or  less  completely  when 
the  inflammation  has  worked  its  way  to  the  surface  of  the  body. 

Diagnosis  of  Bone  Tuberculosis. — The  diagnosis  of  tuberculosis  of 
bone  is  easy  in  the  case  of  primary  tubercular  periostitis,  particularly 
if  the  bone  is  superficial,  and  the  characteristic  swelling,  tenderness  on 
pressure,  etc.,  are  present.  The  diagnosis  of  bone  tuberculosis  may 
occasionally  be  doubtful  for  some  time,  but  still  its  beginning  and  sub- 
sequent course  in  different  parts  of  the  body,  as  we  shall  see  in  the  Spe- 
cial Surgery,  is  generally  so  typical  that  the  diagnosis  is  not  very  diflft- 
cult  (see  also  §  83,  Tuberculosis). 

Prognosis  of  Bone  Tuberculosis. — As  regards  the  termination  and 
the  prognosis  of  tuberculosis  of  bone,  I  must  refer  the  reader  to  what 
has  been  stated  in  §  83.  Suffice  it  to  say  that  the  location  of  tuber- 
culosis of  bone  plays  a  very  important  part  as  regards  prognosis — i.  e., 
in  so  far  as  it  determines  whether  the  existing  focus  can  be  completely 
removed  by  operative  measures  at  the  earliest  possible  stage,  or  whether 
other  local  treatinent,  such  as  iodoform  injections,  can  be  employed. 
If  the  latter  is  impracticable,  as  may  often  be  the  case  in  tuberculosis 
40 


fi20  INJURIES   AND   SURGICAL   DISEASES   OF   BONE. 

of  the  vertebrae,  spontaneous  recovery  can  probably  only  take  place 
when  the  focus  is  not  too  large.  In  the  majority  of  instances  the  tuber- 
cular disease  steadily  progresses  or  very  often  leads  to  tubercular  sys- 
temic infection.  Recurrences  in  tuberculosis  are  pretty  common,  and 
permanent  cures  do  not  occur  so  frequently  as  many  enthusiasts  believe 
(see  §  83). 

The  Treatment  of  Tuberculosis  of  Bone. — In  the  first  stages  of  a  de- 
veloping tuberculosis  of  bone  the  treatment  is  purely  symptomatic 
(rest,  innnobilising  di-essings,  ice,  good  food,  fresh  air,  etc.).  As  soon 
as  possible  I  then  begin  in  suitable  cases  with  parenchymatous  injec- 
tions of  sterilised  ten  per  cent,  iodoform  oil,  or  the  iodoform  glycerine 
of  Bruns,  which  I  can  most  heartily  recommend  (two  to  eight  grannnes 
every  two  to  four  weeks).  At  present  I  always  use  ten-per-eent.  iodo- 
form oil.  The  iodoform  and  oil  are  sterilised  separately  by  heating 
them  in  a  sterilising  apparatus  to  100°  C.  (212°  F.) ;  the  sterilised 
materials  are  then  cooled  and  made  into  a  ten-per-cent.  iodoform  mix- 
ture in  a  sterilised  vessel.  Instead  of  ol.  olivse,  Bohm  recommends  ol. 
amygd.  dulc,  in  which  is  dissolved  fifty  per  cent,  of  iodoform.  If  the 
iodoform  oil  is  prepared  in  the  manner  described  above,  M^e  avoid  the 
injurious  effects  or  poisonous  manifestations  of  the  iodoform,  which  ai'e 
mainly  caused  by  the  liberation  of  iodine.  The  latter  is  particularly 
apt  to  be  set  free  if  tlie  iodoform  and  oil  are  sterilised  together  at  high 
temperatures  when  in  the  form  of  an  emulsion.  Lannelongue  praises 
the  results  obtained  by  the  injection  of  strong  solutions  of  chloride  of 
zinc  into  the  periphery  of  the  tubercular  focus ;  a  contracting,  cicatrix- 
like  tissue  is  thus  produced,  which  forms  an  obstruction  to  the  spread 
of  the  tubercular  process  and  causes  the  death  of  the  tubercular  focus. 
I  have  little  to  say  in  favour  of  parenchymatous  injections  of  three- 
per-cent.  solutions  of  carbolic  acid  or  arsenic.  Balsam  of  Peru  and 
cinnamic  acid  are  spoken  of  on  page  420.  Nannotti  recommends  oil 
of  cloves  (ten  per  cent.,  with  olive  oil) ;  Ileboul,  naphthol  caniphre  ob- 
tained by  mixing  and  heating  one  hundred  parts  of  finely  powdered  /3 
naphthol  with  two  hundred  parts  of  finely  powdered  Japan  camphor. 
The  oily  liquid  of  naphthol  camphre  is  insoluble  in  water,  but  miscible 
with  fats,  ether,  alcohol,  and  chloroform,  and  must  be  kept  in  a  dark 
bottle.  The  remedy  can  be  employed  in  various  ways — as  a  wash,  an 
injection,  etc.  Bouchard  states  that  its  toxic  dose  for  adults  is  about 
two  hundred  and  fifty  grammes. 

If  treatment  by  drugs  proves  unsuccessful,  and  a  marked  focus  of 
disease  or  of  pus  is  present,  operative  treatment  should  be  undertaken — 
i.  e.,  the  tubercular  deposit  should  be  removed  as  soon  as  possible,  with 
strict  regard  to  antisepsis.    Oi)erations  on  the  extremities  are  performed 


?J  105.]  TIIK   ClIKOXKi   INFLAMMATIONS  OF   BONK.  627 

under  Esinarch's  artilicial  iscliagmia,  \vliiclT*renders  it  possible  to  easily 
distinguish  the  healthy  from  the  diseased  parts.  Free  incisions  should 
always  be  made,  in  order  that  the  focus  may  be  inspected  througlix>ut 
its  entire  extent.  Mosetig-Moorhof  finds  an  electric  lamp  useful  for 
this  purpose.  If  the  tuberculosis  is  in  the  meduUa,  the  bone  should  be 
opened  sutlieicntly  with  the  chisel  and  luunmcr,  and  the  tubercular 
focus  should  be  energetically  removed  with  the  sharp  spoon.  The 
scraping-out  process  must  be  ccuitinued  until  healthy,  firm  bone  is 
reached.  Even  when  the  entire  medullary  cavity  of  a  long  bone  has  to 
be  thus  scraped  out,  necrosis  will  not  occur  if  only  the  wound  in  the 
bone  heals  aseptically.  To  prevent  recurrences  and  to  render  speedy 
recovery  possible,  liiedel  recommends  extensive  removal  of  the  bone, 
leaving  only  a  thin  wall  of  cortex  intact.  Free  sequestra  should  be  ex- 
tracted ;  infected  soft  parts  in  the  neighbourhood  of  the  diseased  bone, 
abscess-  membranes,  etc.,  should  likewise  be  removed  with  the  greatest 
care  by  scissors  and  forceps.  After  having  scraped  out  the  tubercular 
deposit  in  the  bone,  the  resulting  cavity  should  be  filled  with  ten  per 
cent,  iodoform  oil  and  packed  with  iodoform  gauze.  Billroth's  method 
is  most  excellent  and  efiicacious.  The  tubercular  cavity,  in  case  it  has 
not  opened  externally  before  the  operation,  is  immediately  filled  with 
ten  per  cent,  iodoform  oil  or  iodoform  glycerine,  and  hermetically  closed 
after  all  tubercular  tissue  has  been  removed  with  the  sharp  spoon.  The 
iodoform  acts  more  efliectively  in  the  absence  of  air. 

If  any  recurrences  take  place,  they  are  soon  recognised  by  the  per- 
sistence of  fistulie  with  fungous  tissue.  The  secondary  operation 
should  not  be  delayed  too  long.  Operations  must  often  be  performed 
two,  three,  or  more  times,  with  short  intervals,  before  a  complete  cure 
is  obtained.  The  cold  al)scess,  which  used  to  be  a  7ioli  me  tangere  to  the 
old  surgeons  on  account  of  the  pyismia  which  so  frequently  followed 
the  operation,  must  always  be  o])ened  at  the  earliest  possible  moment, 
scraped  out  and  drained.  The  treatment  of  tubercular  inflammations 
of  joints  will  be  discussed  under  the  subject  of  Diseases  of  Joints 
(§  114).  The  indications  for  amputation  and  resection  are  described 
on  pages  113  and  120.  All  operations  in  cases  of  tuberculosis  should 
be  performed  with  the  greatest  care  and  most  rigid  asepsis.  We  men- 
tioned, in  first  speaking  of  tuberculosis,  that  general  miliary  tubercu- 
losis may  occasionally  follow  operations  on  tubercular  foci,  as  well  as 
vigorous  movements  of  joints  affected  with  tubercular  disease. 

Iodoform  and  iodoform  gauze  are  the  best  materials  for  dressings 
in  cases  of  tuberculosis,  and  large  wounds  may  be  packed  with 
them.  Instead  of  packing  with  iodoform  gauze.  Schede's  plan  of 
obtaining    healing   under   an    aseptic    blood-clot  without  drainage   is 


628  INJURIES  AND  SURGICAL   DISEASES  OP  BONE. 

also  very  serviceable  after  scraping  out  the  tubercular  deposit  (see 
page  102). 

The  treatment  of  tuberculosis  of  bone  Math  Kocli's  tuberculin  is 
discussed  on  page  421.  I  have  obtained  no  permanent  cures  by  this 
means,  and  sometimes  matters  have  been  made  decidedly  worse. 
Kraske,  among  otliers,  has  had  the  same  experience. 

In  tuberculosis  it  is  very  important  that  the  constitution  of  the 
patient  should  be  strengthened  by  energetic  general  treatment,  in  the 
manner  described  on  pages  421  and  424. 

The  Syphilitic  Diseases  of  Bone. — Syphilis  of  bone  occurs  in  the 
later  stages  of  syphilis  (§  84),  either  in  the  form  of  death  of  bone,  as 
caries  and  necrosis,  or  as  an  ossifying  inilammation  of  bone.  The  in- 
flammation of  bone  characteristic  of  syphilis  is  the  gummatous  perios- 
titis and  osteomyelitis — i.  e.,  the  formation  of  gummata  or  syphilo- 
mata  in  the  periosteum  or  medulla.  The  periosteal  gummata  take  the 
form  of  flat,  elastic  swellings,  which  on  section  reveal  a  gelatinous  con- 
sistency. 

In  the  later  stages  a  fatty,  cheesy,  or  a  suppurative  degeneration 
takes  place,  with  or  without  shrinkage  to  firm  fibrous  thickenings. 
The  periosteal  gumma  is  very  apt  to  occur  'on  the  skull,  and  also  not 
infrequently'^  in  the  periosteum  inside  the  cranial  cavity,  less  often  on 
the  clavicle,  and  rarely  on  the  dia]>hyses  of  the  long  bones.  The  ejiiph- 
yses  of  the  latter  and  the  short  bones  are,  almost  without  exception, 
exempt  from  gunnnata. 

The  osteomyelitic  gummatous  nodes  are  soft  or  more  fibrous  gelat- 
inous formations,  varying  from  about  the  size  of  a  pea  to  that  of  a 
nut,  and  usually  cheesy  in  the  centre.  They  are  sometimes  multiple, 
being  found,  for  example,  on  the  skull,  on  the  phalanges,  and,  accord- 
ing to  Chiari,  also  on  the  long  bones,  the  femur  and  tibia  being  the 
most  frequently  affected. 

Both  periosteal  and  osteomyelitic  gummata  destroy  the  bone  to  a 
greater  or  less  extent,  and  lead  to  a  varying  amount  of  superficial  or 
central  caries  with  necrosis.  In  consequence  of  this  death  of  bone 
fractures  readily  occur,  and  not  infrequently  are  followed  by  pseudar- 
throsis.  The  syphilitic  caries  with  necrosis  is  particularly  apt  to  make 
its  appearance  on  the  skull,  and  sometimes  is  very  extensive  (see  Spe- 
cial Surgery).  A  reactive  new  formation  of  bone  also  occurs  as  a  re- 
sult of  the  gummatous  periostitis  and  osteomyelitis  ;  it  leads  to  the 
development  of  osteophytes  of  varying  dimensions,  and  also  to  hj'per- 
trophy  and  sclerosis  of  the  bone. 

The  gummata  either  disappear  under  appropriate  antisyphilitic 
treatment  by  becoming  gradually  absorbed  and  replaced  by  dense  cica- 


4^  105.]  THE  CHRONIC   INFLAMMATIONS  OF  BONE.  629 

tric'ial  tissue  or  newly  foi-ined  bone  tissue,  or  else  a  spreading  destruc- 
tion and  necrosis  of  bi)ne  develops,  the  guniniata  open  externally,  etc. 

Apart  from  the  reactive  develoi>nient  of  new  bone  with  the  forma- 
tion of  osteo})liytes  and  diffuse  hyperostoses  accompanying  gummata, 
there  is  also  an  independent  ossifying  sypliilitic  ostitis,  a  j)eriostitis 
and  osteomyelitis,  which  occur  alone. 

In  congenital  syphilis  there  is  observed  a  characteristic  disease  of 
the  bones  in  the  neighbourhood  of  the  epiphyses,  consisting  in  some 
cases  in  an  abnormity  in  the  deposit  of  lime,  and  in  the  formation  of 
medullary  spaces  such  as  occurs  in  rhachitis.  This  syphilitic  rhachitis 
is  not  very  common.  But  in  other  cases  of  congenital  syphilis  a  very 
characteristic  localised  disease  is  present  in  the  epipliyses,  particularly 
in  the  part  near  the  articular  and  epiphyseal  cartilages.  This  syphilitic 
osteochondritis  of  infants,,  first  described  by  Wegner,  is  in  fact  a  com- 
mon though  not  a  constant  manifestation  of  hereditary  syphilis.  The 
disease  consists  in  the  formation  of  greyish-red  or  yellowush-grey  foci 
in  the  medulla  of  the  epiphyses  in  the  neighbourhood  of  the  articular 
and  epiphj'seal  cartilages.  The  bone  becomes  replaced  by  a  soft  granu- 
lation tissue,  and  the  cartilage  itself  is  in  a  state  of  inllanmiatory 
growth.  Separation  of  the  epiphysis  sometimes  occurs  in  syphilitic 
osteochondritis,  as  it  does  after  acute  infectious  osteomyelitis.  Kasso- 
witz  found  this  condition  nine  times  in  thirty-three  cases.  Epiphyseal 
separations  have  also  not  infrequently  been  observed  in  still-born  syphi- 
litic children  (Ilaab,  Veraguth,  etc.),  but  under  these  circumstances  the 
separations  may  possibly  have  been  caused  by  putrefactive  changes  as 
well  as  by  the  syphilitic  osteochondritis. 

The  course  of  the  syphilitic  inflammations  of  bone,  which  occur 
especially  in  the  later  so-called  tertiary  period  of  the  disease  and  in  the 
cases  which  have  been  improperly  treated,  is  for  the  most  part  very 
chronic  and  marked  by  frequent  relapses.  They  have  been  wrongly 
ascribed  to  the  effects  of  mercury.  Ostitis  due  to  mercury  is  only  ob- 
served as  a  result  of  salivation  ulcers  on  the  jaws.  Traumatism  appears 
to  play  an  important  part  in  the  syphilitic  inflammations  of  bone.  The 
severe  pains  (dolores  osteocopi),  which  occur  principally  at  night,  are 
often  characteristic. 

The  treatment  of  the  syphilitic  inflammations  of  bone  consists  in 
the  adoption  of  a  general  antisyphilitic  regimen  (see  §  84).  The  local 
treatment  of  the  syphilitic  metastases  is  conducted  according  to  general 
principles,  and  is  similar  to  that  briefly  described  for  tuberculosis  of 
bone. 

The  So-called  Bone  Abscess. — We  have  made  repeated  mention  of 
the  so-called  chronic  bone  abscess  which  occurs,  for  example,  after 


630  INJURIES  AND   SURGICAL   DISEASES   OF   BONE. 

acute  infectious  osteomyelitis  and  tuberculosis  of  bone.  It  is  always 
infectious  in  its  nature  and  arises  in  various  diseases,  and  is  not,  as  was 
once  believed,  an  independent  disease,  but  always  a  symptom  or  a  result 
of  a  pre-existing  specific  disease.  Hence  it  follows  that  the  causes  of 
abscess  of  bone  vary  very  greatly.  The  acute  suppurative  inflamma- 
tions of  the  periosteum  and  medulla,  the  tubercular  and  syphilitic  in- 
flammations of  bone,  etc.,  are  especially  conducive  to  the  development 
of  chronic  bone  abscesses.  The  so-called  acute  bone  abscesses  are 
essentially  metastatic  in  their  nature  or  originate  as  a  primary  acute 
infectious  osteomyelitis. 

The  symptomatology  and  treatment  of  abscess  of  l)one  can  be 
inferred  from  what  has  been  said  concerning  acute  and  chronic  suppu- 
ration of  bone. 

Other  Bone  Diseases:  Actinomycosis;  Glanders. — Amongst  other 
chronic  diseases  of  bone,  I  should  mention  actinomycosis  and  the  cir- 
cumscribed cheesy  or  suppurative  inflammations  which  occur  in  the 
periosteum  and  medulla  in  the  course  of  glanders.  Both  diseases  have 
been  described  in  §  78  and  §  86. 

^  §  106.  Necrosis  of  Bone. — We  have  repeatedly  spoken  of  the  death 
of  bone  or  of  a  certain  portion  of  bone — the  so-called  necrosis  of  bone 
— when  discussing  the  subject  of  Injuries  and  Inflammations  of  Bone. 

The  causes  of  necrosis  of  bone  are  sometimes  inflanmiatory  and 
sometimes  traumatic  in  their  nature.  In  typical  necrosis  of  bone  there 
is  almost  always  an  interruption  of  the  afferent  flow  of  blood,  less  often 
a  direct  death  of  the  bone  substance.  Amongst  the  special  causes  of 
necrosis  the  diseases  of  the  periosteum  and  medulla  are  the  most  im- 
portant. It  is  principally  the  suppurative  form  of  periostitis  which 
very  frequently  leads  to  necrosis;  but  any  suppurative  periostitis,  as 
such,  will  not  cause  necrosis  of  bone  until  it  has  existed  a  long  time 
and  has  extended  to  the  contents  of  the  Haversian  canals.  The  suppu- 
rative periostitis  is  frequently  the  result  of  a  necrosis  due  to  other 
causes. 

Necrosis  is  also  produced  by  the  various  forms  of  ostitis  and  osteo- 
myelitis when  the  bone  tissue  becomes  unable  to  obtain  nourishment, 
owino;  to  the  destruction  of  the  medulla  and  the  contents  of  the  Haver- 
sian  canals.  In  this  class  of  cases  comes,  for  example,  the  necrosis  from 
.  suppurative  osteomyelitis  and  tuberculosis  of  bone,  mentioned  in  a 
previous  chapter. 

Suppurative  inflammations  of  the  surrounding  parts  and  ulcerative 
processes  which  extend  to  and  destroy  the  periosteum  likewise  lead  to 
necrosis.  In  this  manner  is  caused,  for  example,  the  necrosis  of  the 
nasal  bones,  which  occurs  in  the  course  of  syphilis  from  the  extension 


§10G.]  NECROSIS   OF    HONE.  631 

of  ulceration  in  the  nasal  mucous  nienihi-ane  to  the  deeper  parts  (oztena 
syphilitica). 

The  necrosis  occurring  in  the  course  of  typhoid  fever  and  the  acute 
exanthemata  is  due  in  some  instances  to  metastatic  periostitis  and  osteo- 
myelitis, while  in  others  it  is  probably  a  kind  of  inanition  necrosis  which 
is  the  result  of  the  general  disturbance  of  nutrition.  As  a  matter  of  fact 
the  state  of  the  nutrition  of  such  individuals  is  generally  extremely  bad, 
and  they  suffer  for  the  same  reason  from  gangrene  of  the  ears  and  nose. 

In  rare  instances  necrotic  foci  in  bone  originate  from  emboli.  Volk- 
mann  saw  a  multiple  necrosis  of  the  astragalus  and  tibia  which  followed 
the  formation  of  coagula  on  the  mitral  valve  in  endocarditis.  In  these 
cases  we  generally  have  to  do  with  multiple  capillary  emboli,  and  in  the 
case  of  infectious  processes  these  emboli  may  consist  of  micro-organisms 
which  have  entered  the  circulation.  Embolism  of  a  single  nutrient 
artery  of  the  bone  would  probably  never  be  followed  by  appreciable  con- 
sequences, for  the  reason  that  a  collateral  circulation  readily  develops, 
and  the  blood  is  carried  to  the  bone  by  very  many  and  for  the  most 
part  very  small  vessels. 

The  phosphorus  necrosis,  first  described  by  Lorinser,  of  Vienna,  in 
1845,  is  extremely  interesting.  It  is  observed  in  people  employed  in 
the  manufacture  of  phosphorus  matches,  and  is  due  to  the  injurious 
effects  of  the  vapour  of  phosphorus.  Phosphorus  necrosis  only  affects 
the  bones  of  the  face,  and  selects  the  jaw  almost  always — the  inferior 
maxilla  more  frequently  than  the  superior.  The  disease  regularly  be- 
gins with  inflammatory  disturbances  in  the  periosteum  (phosphorus 
periostitis,  Wegner),  especially  where  there  are  diseased  (carious)  teeth. 
At  first  a  chronic  ossifying  periostitis  usually  develops,  then,  as  a  result 
of  infection  by  bacteria  in  the  oral  cavity,  suppuration  and  gangrene 
follow  between  the  periosteum  and  new  bone,  or  between  the  new  and 
old  bone.  Sometimes,  though  rarely,  the  disease  begins  immediately 
with  suppuration  and  necrosis  without  a  preceding  ossifying  periostitis. 
The  entire  lower  jaw  may  become  necrotic,  especially  if  the  process  is 
not  arrested  by  early  removal  of  the  focus  of  disease.  Hackel  states 
that  the  average  duration  of  the  disease  from  the  time  the  periostitis 
begins  till  the  suppuration  and  necrosis  of  the  under  jaw,  for  example, 
ceases,  is,  when  the  disease  is  left  to  itself — for  the  inferior  maxilla  two 
years  nine  and  a  half  months,  and  for  the  superior  maxilla  one  year 
and  two  months.  Since  the  manufacture  of  phosphorus  matches  has 
become  less  extensive,  and  strict  hygienic  regulations  have  been  enforced 
in  the  factories,  phosphorus  necrosis  has  become  rare ;  but  it  still  occurs 
in  regions  such  as  the  Thuringian  Forest,  where  the  making  of  phos- 
phorus matches  is  carried  on  as  a  family  industry. 


632 


INJURIES  AND   SURGICAL   DISEASES   OF   BONE. 


Necrosis  develops  after  a  traumatism,  particiilai-ly  if  portions  of  the 
bone  are  completely  torn  off  or  separated  from  their  attachments — a  fact 
which  we  learned  when  discussing  fractures  (see  §  101).  We  stated  at 
that  time  that  in  fractures  which  heal  asepticallj  and  in  those  which 
are  subcutaneous,  pieces  of  bone  which  have  been  completely  detached 
may  again  heal  in  place  and  not  undergo  necrosis.  After  subcutaneous 
dislocation  of  the  astragalus,  Winiwarter  observed  total  necrosis  of  the 
bone  occur  in  two  instances  in  spite  of  its  having  been  carefully  re- 
placed. Furthermore,  when  a  bone  has  been  severely  splintered  and 
crushed,  circumscribed  necrosis  is  particularly  apt  to 
develop  if  the  arterial  vessels  in  the  medullary  space  or 
narrow  Haversian  canals  are  compressed — by  an  ex- 
travasation of  blood,  for  example.  Traumatic  separa- 
tion of  the  periosteum  laying  bare  the  bone  does  not  of 
itself  lead  to  necrosis,  bnt  the  latter  will  develop  if  the 
bone  becomes  dry  from  long  contact  with  the  air,  or  if 
suppuration  takes  place. 

Anatomical  Changes  in  Necrosis;  Separation  of  the 
Sequestrum  (Demarcation). — When  a  portion  of  a  bone 
has  perished  it  is  gradually  separated  or  set  free  from 
the  surrounding  living  bone  by  a  demarcating  inflam- 
mation. The  separation  of  the  dead  bone — the  demar^ 
cation,  as  it  is  called — is  designated  anatomically  as  a 
granulating,  rarefying  ostitis,  the  bone  disappearing  by 
lacunar  absorption  (see  Fig.  343)  along  the  line  of  de- 
marcation. The  piece  of  bone,  after  it  has  become 
completely  separated,  is  called  a  sequestrum  (Fig.  352, 
a,  and  Fig.  353,  s).  The  outer,  periosteal,  cortical  sur- 
face of  the  sequestrum  ordinarily  remains  smooth,  while 
the  other  portions  of  the  seqnestrum,  wdiere  it  is  gradually  set  free 
from  the  living  bone  by  the  demarcation,  appear  rough  and  uneven, 


Fig.  352.— Necro- 
sis of  bone  (fe- 
mur) :  a,  se- 
questrum. 


Fig.  353. — Complete  necrosis  of  the  diapli ysis  of  the  tibia  :  -S',  sequestrum  ;  a  a,  flstulfe  (cloacae) ; 
b,  newly  formed  bone  or  involucrum  (schematic). 

just  like  the  ivory  pegs  which  have  been  driven  into  a  bone  for  pseu- 
darthrosis  (see  Fig.  347).     The  size  of  every  sequestrum  is  rendered 


f?  106.]  NP]C110SIS  OP   BONE.  533 

less  by  this  corrosion  or  abrasion,  and,  in  fact,  small  sequestra,  like 
small  splinters  of  bone  in  fractures,  may  be  completely  absorbed  if 
there  is  no  suppuration  and  the  granulating  germinal  tissue  surrounds 
them  closely.  As  is  the  case  in  the  corrosion  of  the  ivory  pegs,  so 
also  in  the  separation  of  the  secpiestra  and  the  absorption  of  small 
sequestra  it  is  mainly  the  carbonic  acid,  resulting  from  the  metabolism 
of  the  tissues,  which  in  the  free  state,  together  with  the  osteoclasts, 
dissolves  the  lime  salts.  The  length  of  time  occupied  by  the  process 
of  demarcation  till  the  sequestrum  has  been  completelv  separated  varies 
greatly,  and  depends  upon  the  size  of  the  sequestrum  and  its  location. 
The  activity  of  the  separating  process  in  different  individuals  is  also 
very  variable.  In  general  it  may  be  said  that  extensive  necroses,  such 
as  the  total  necrosis  of  a  diaphysis,  require  in  some  instances  from  three 
to  five  months,  and  in  others  from  eight  to  ten  to  twelve  months,  be- 
fore they  are  completely  separated.  Separation  of  the  sequestrum 
takes  place  more  rapidly  in  young  than  in  old  patients. 

Hand  in  hand  with  the  separation  of  the  dead  portion  of  bone  its 
regeneration  proceeds  by  reactive  bone  formation — i.  e.,  by  an  ossifying 
periostitis  and  osteomyelitis — as  in  the  repair  of  fractures.     Through 
the  action  of  the  periosteum  a  cap- 
sule of  bone — the  involucrum,  as  it 
is  called — is  formed  around  the  se- 
questrum, as  in  the  case  of  necrosis 
of  the  entire  diaphysis  (Fig.  353,  h, 
and    Fig.    354,    h).      The     Ustulge 
which  lead   from   the   involucrum 
to   the   surface    of    the   body   are 
called  cloacfe,  an  expression  which    ^'^- ^^i~uv'^l''lw  f.?''  ?f ''  '^o^'«^,^«'^f  = 

'  r  //,  cavity  in  the  bone  after  removal  of  the 

has  passed  out  of  use  at  the  present  sequestrum ;«,  fistula :   b,  newly  formed 

^  *  bone  or  involucrum  (schematic). 

time.      Through    these  cloacae,  or, 

better,  fistulte,  the  pus  escapes  from  the  cavity  containing  the  seques- 
trum (Fig.  353,  a,  and  Fig.  354,  a).  Large  defects  develop  especially 
in  those  parts  of  the  involucrum  where  the  periosteum  has  perished  in 
consequence  of  suppuration  or  a  traumatism.  In  cases  of  central 
necrosis — i.  e.,  necrosis  in  the  interior  of  a  bone — the  innermost  layers 
of  the  involucrum  are,  of  course,  formed  from  portions  of  the  old  in- 
tact bone.  But  even  in  these  central  necroses  there  usually  occurs  a 
reactive  ossifying  periostitis  with  the  formation  of  fresh  layers  of  bone. 
The  capabilities  of  regeneration  possessed  by  bones  (a  subject  which 
has  been  thoroughly  investigated  by  Oilier)  are  in  general  very  great, 
and  a  necrosis  which  involves  the  whole  of  a  long  bone  can  be  so  com- 
pletely compensated  for  that  no  variations  from  the  normal  will  be 


634  INJURIES  AND  SURGICAL  DISEASES  OF   RONE. 

noticed.  Bat  occasionally  the  regeneration  is  defective,  or  may  even 
be  entirely  absent  and  permit  the  defect  to  persist.  Not  infrequentl}', 
in  the  case  of  a  necrosis  involving  the  diaphysis  of  a  long  bone  in  a 
young  subject,  there  will  be  observed,  in  consequence  of  the  irritation 
of  the  epiphyseal  cartilages,  an  increased  longitudinal  growth  causing 
the  bone  in  question  to  become  two  to  three  centimetres  longer  than 
the  corresponding  one  on  the  sound  side. 

Various  Kinds  of  Necrosis  Distinguished  by  their  Location  and  Extent. 
— Accordino;  to  the  situation  and  extent  of  the  necrosis  we  recognise  a 
superficial,  external,  or  peripheral  necrosis  in  contradistinction  to  the 
above-mentioned  central  necrosis  occurring  in  the  interior  of  a  bone. 
We  also  recognise  a  partial  and  a  total  necrosis,  and  a  nmltiple  necro- 
sis occurring  in  different  portions  of  the  same  bone  or  in  several  bones 
of  the  same  skeleton.  The  necrosis  tubulata  (Blasius)  with  a  tubular- 
shaped  sequestrum  is  very  rare  ;  the  internal  axis  of  the  sequestrum  is 
formed  of  living  bone  substance  which  is  firmly  connected  with  the  old 
bone.  Consequently  we  have  to  deal  with  tubular  sequestra  in  which 
there  is  a  preservation  of  -the  innermost  layers  of  bone  or  a  consider- 
able regeneration  of  the  latter  by  an  ossifying  periostitis. 

Symptomatology  and  Diagnosis  of  Necrosis. — The  symptoms  caused 
by  necrosis  have  already  been  partly  described.  They  are  mainly  due 
to  the  demarcating  inflammation  and  regenerative  new  formation  of 
bone  for  casting  off  and  replacing  the  dead  portion,  which  come  more 
and  more  into  prominence  after  the  subsidence  of  the  primary  disease 
(periostitis,  osteomyelitis).  If  there  has  been  a  loss  of  substance  in 
the  overlying  soft  parts  the  dead  bone  will  be  plainly  visible ;  but  if 
the  necrotic  bone  is  covered  by  soft  parts,  and  if  the  sequestrum 
is  deeply  situated,  the  bone  will  ordinarily  be  found  to  be  evenly 
thickened  at  the  affected  point,  as  a  result  of  the  ossifying  periostitis 
(Figs.  353,  35-i).  The  presence  of  fistulous  tracts,  which  usually 
discharge  only  a  little  pus,  is  another  symptom  of  necrosis  of  bone.  If 
a  metal  probe  is  passed  through  these  fistulous  passages  it  will  usually 
strike  the  surface  of  the  sequestrum.  The  latter  feels  hard,  and  if 
percussed  with  the  probe  emits  a  tympanitic  sound.  In  the  case  of 
superficial  or  total  necrosis  the  surface  of  the  sequestrum  is  smooth ;  if 
the  necrosis  is  central  the  surface  is  rough.  The  dead  bone  is  also 
recognisable  by  its  lack  of  blood,  and  by  its  white  colour  when  com- 
pared to  the  rosy  appearance  of  the  living  bone.  It  is  very  impor- 
tant, both  for  diagnosis  and  treatment,  to  determine  whether  the  se- 
questrum has  become  movable.  The  mobility  of  the  sequestrum  can 
be  ascertained  by  pressing  the  probe  firmly  against  it,  or  by  pass- 
ing two  probes  through  two  different  fistulte  down  to  the  sequestrum, 


g  lOG.]  NECROSIS  OP   RONE.  (}35 

or  finally  by  attempting  to  move  it  back  and  fortli  by  means  of  a 
dressing  forceps.  Occasionally  a  se(piestrnm  which  has  become  en- 
tirely free  is  so  tightly  enclosed  that  it  is  impossible  to  demonstrate  its 
mobility.  In  such  cases  the  separation  of  the  sequestrum  is  deter- 
mined by  the  duration  of  the  disease.  Necrosis  may  be  mistaken  for 
those  central  bone  diseases  which  lead  to  enlargement  of  the  bone  with 
the  formation  of  fistulae,  such  as  central  bone  abscesses  and  tumours  of 
bone,  and  then  particularly  for  caries.  The  typical  caries,  with  few 
exceptions,  as  we  saw,  is  a  tul)ercular  process,  and  is  very  often  com- 
bined with  necrosis.  The  tubercular  sequestra  usually  contain  cheesy 
tissue  and  have  a  soft  feeling,  while  the  sequestra  of  ordinary  necrosis 
appear  white  and  hard,  like  normal  bone.  The  pus  in  necrosis  is  scanty 
and  more  mucoid,  but  in  caries  it  is  a  thin  liquid  mixed  with  cheesy 
masses.  The  fistulous  tracts  of  tuberculosis  generally  have  a  pale, 
lardaceous  appearance,  and  if  a  probe  is  introduced  through  them  it 
strikes  against  soft,  crumbling  bone ;  while  in  necrosis  the  granulations 
usually  have  a  vigorous,  healthy  appearance  and  bleed  easily,  and  the 
sequestrum  when  touched  by  the  probe  feels  hard.  Furthermore,  the 
development  of  the  two  diseases  is  different.  The  tubercular  caries 
begins  gradually,  and  mainly  affects  the  epiphyses  and  the  spongy 
bones,  while  the  typical  necrosis  ordinarily  develops  after  acute  or  sub- 
acute inflannnation  of  bone,  especially  the  long,  hollow  bones  (femur, 
tibia,  humerus). 

Treatment  of  Necrosis.— The  treatment  of  necrosis  before  the  se- 
questrum has  separated  is  purely  symptomatic,  and  consists  mainly  in 
keeping  the  fistulas  clean.  When  the  sequestrum  has  become  com- 
pletely free  it  must  be  removed  by  operation,  if  it  has  not  already 
been  spontaneously  cast  off  or  out.  Even  large,  deeply  located  se- 
questra can  work  their  way  outwards  through  the  cloacae  and  come  to 
lie  beneath  the  skin,  which  they  then  gradually  penetrate.  I  extracted 
simply  with  the  fingers,  in  the  case  of  a  twelve-year-old  boy,  a  large, 
completely  separated  sequestrum  consisting  of  the  entire  thickness  of 
the  femur.  During  many  months  it  had  projected  several  centimetres 
from  the  soft  parts,  and  no  one  had  dared  remove  it.  As  a  rule,  only 
those  sequestra  which  are  completely  free  should  be  removed,  but 
there  are  a  few  exceptions  to  this.  In  the  case  of  phosphorus  necrosis, 
for  instance,  the  foul  suppuration  compels  us  to  adopt  operative  meas- 
ures before  the  sequestrum  has  become  completely  separated,  and  early 
resection — i.  e.,  early  removal  of  the  primary  focus  of  disease — should 
be  undertaken  to  shorten  the  process  and  to  prevent  it  from  extending 
further.  If  the  disease  is  left  to  itself,  the  entire  lower  jaw  perishes, 
according  to  Hackel,  in  seventy-nine  per  cent,  of  the  cases.    In  ordinary 


636  INJURIES  AND  SURGICAL   DISEASES   OF   BONE. 

necrosis  we  must  wait  for  the  separation  of  the  sequestrum  to  become 
complete,  for  the  reason  that  the  loss  of  substance  will  have  been  re- 
placed by  a  new  formation  of  bone,  and  that  if  we  operate  before  the 
separation  is  complete  we  are  liable  to  remove  too  much  of  the  healthy 
bone,  or  possibly  too  little  of  that  which  is  dead.  In  doubtful  cases, 
where  the  mobility  of  the  sequestrum  cannot  be  determined,  the  length 
of  time  the  process  has  lasted  must  be  taken  into  consideration  in  de- 
ciding whether  or  not  operative  removal  of  the  sequestrum  should  be 
undertaken.  On  the  other  hand,  when  the  necrosis  is  extensive,  though 
the  sequestrum  be  free,  the  operation  should  be  postponed  if  the  new 
formation  of  bone  is  too  scanty. 

The  Operative  removal  of  the  Sequestrum  (Sequestrotomy). — If  the 
necrosis  is  not  encapsulated,  the  tistulaj  are  simply  enlai-ged  to  the 
necessary  amount  with  the  knife  and  the  sequestrum  extracted  with 
suitable  forceps,  such  as  a  dressing  forceps.  If  the  sequestrum  is  en- 
capsulated by  an  involucrum,  the  latter  must  be  opened  with  the  ham- 
mer and  chisel  after  freely  dividing  the  soft  parts  and  elevating  the 
periosteum.  Esmarch's  artificial  ischemia  should  be  used  for  the  ex- 
tremities. After  extraction  of  the  sequestrum  the  cavity  in  the  bone 
should  be  thoroughly  scraped  out,  and  then  either  packed  with  iodo- 
form gauze,  or  the  wound  in  the  soft  parts  closed  almost  entirely  by 
sutures,  after  providing  for  drainage.  If  the  wound  is  left  to  granu- 
late, the  skinning-over  process  can  be  hastened  later  on  by  the  trans- 
plantation of  skin.  Schede's  method  of  obtaining  healing  under  an 
aseptic  blood-clot  (see  page  102)  is  also  good— i.  e.,  the  wound  in  the  soft 
parts  is  closed  by  sutures  without  drainage,  though  I  leave  one  angle 
open  as  a  means  of  escape  for  any  surplus  accumulation  of  tluid.  To 
prevent  recurrences  and  to  obtain  speedy  recovery,  the  involucrum 
should  be  removed,  as  Riedel  rightly  says,  until  only  a  wall  of  cortex 
remains  in  the  form  of  a  flat  trough.  If  the  operation  has  been  per- 
formed under  Esmarch's  artificial  ischemia,  antiseptic  dressings  exert- 
ing pressure  should  be  applied,  and  the  extremity  elevated,  before  the 
rubber  tourniquet  is  removed  ;  the  limb  should  then  be  kept  elevated 
for  the  next  twelve  to  twenty-four  hours.  It  is  very  important  that 
the  extremity  which  has  been  operated  upon  should  be  innnobilised  as 
much  as  pf)ssil)le  by  a  splint.  If  fistulne  persist,  they  must  be  thoroughly 
scraped  out,  and  the  seqnestrotomy,  when  necessary,  repeated  for  the 
extraction  of  any  other  sequestra  which  may  be  present.  Sequestrot- 
omy is  a  very  beneficent  and  not  at  all  a  dangerous  operation  if  per- 
formed with  antiseptic  precautions. 

Liicke  and  Bier  have  recommended  an  excellent  new  method  for 
sequestrotomy  which  is  called  osteoplastic  necrotomy  (Fig.  355).     In 


i5  107.]         SPONTANEOUS  SEPARATIONS  OF  THE   EPIPHYSES. 


G37 


the  first  place,  the  incisions  a  c,  al  and  cd  are  made  through  the  soft 
parts,  then  tlie  bone,  which  in  Fig.  355  is  the  tibia,  is  cut  lialf  througli 
transversely  with  a  keyhole 
saw  and  divided  with  the 
chisel  in  the  line  of  the  lon- 
gitudinal incision.  By  de- 
pressing the  handle  of  the 
chisel  the  skin-periosteal-bone 
tlap  thus  fashioned  is  broken 
through  along  the  line  where 
it  still  remains  joined  to  the 
rest  of  the  cortex,  and  is 
turned  back  like  the  lid  of  a 
box,  exposing  the  cavity  con- 
taining the  sequestrum  (see 
Fig.  355).  After  removing 
the  sequestrum  and  scraping 
out  and  disinfecting  the  cavi- 
ty, the  cover  is  replaced,  and 
the  wound  in  the  soft  parts 
closed  immediately  or  by  sec- 
ondary sutures  applied  after 
the  wound  has  first  been 
packed.  Recovery  usually 
takes  place  with  slight  sup- 
puration. ^ 

§  lot.  Spontaneous  (In- 
flammatory) Separations  of  the 
Epiphyses.— The  spontaneous  (inflammatory)  separations  of  the  epiphy- 
ses which  occur  in  the  bones  of  young  subjects  at  the  cartilaginous 
junctions  with  the  diaphyses  have  already  been  discussed  under  the  sub- 
ject of  Suppurative  Periostitis  and  Osteomyelitis.  As  a  matter  of  fact, 
the  spontaneous  separation  of  an  epiphysis  from  the  bone  is  almost 
always  secondary  to  suppurative  inflannnation  of  the  periosteum,  the 
marrow  of  the  bone,  or  the  joint.  But  occasionally  the  epiphyseal 
separation  is  due  to  primary  inflammation  at  the  cartilaginous  sym- 
physis, as,  for  example,  is  the  case  in  the  osteochondritis  luetiea  occur- 
ring in  the  course  of  syphilis.  Multiple  epiphyseal  separations  affect- 
ing several  bones  have  been  observed  in  pysemia.  The  non-suppura- 
tive,  spontaneous  epiphyseal  separation  is  very  rare,  and  when  it  does 
take  place  may  be  due,  according  to  Poupart,  Petit,  and  Volkmann,  to 
a  haemorrhagic  malacia  of  the  epiphyseal  cartilages  occurring  in  scurvy. 


Fig.  355. — Osteopla^itic  necrotomy. 


(538  INJURIES  AND  SURGICAL   DISEASES  OF   BONE. 

The  osteochondritis  dissecans  described  by  KOnig,  the  nature  of  whicli 
is  obscure,  also  sometimes  leads  to  complete  separation,  for  example, 
of  the  head  of  the  femur  from  its  neck,  without  any  traumatism  hav- 
ing been  received,  and  even  occurs  in  people  from  thirty  to  forty  years 
of  age. 

According  to  Volkmann,  the  typical  spontaneous  separation  of  the 
epiphysis  is  generally  observed  before  the  fifteenth  year,  and  no  case 
has  been  recorded  where  it  happened  later  than  the  twentieth  year.  It 
is  well  known  that  the  cartilage  between  the  e})ipliyses  and  diaphyses 
persists  till  about  the  twentieth  to  twenty-second  to  twenty  fourth  year 
of  life,  the  epiphyses  joining  with  the  diaphyses  somewhat  earlier  in 
women  than  in  men.  Separation  of  the  epiphysis  is  most  connnon  at 
the  lower  end  of  the  femur  and  the  upper  end  of  the  tibia. 

Traumatic  separations  of  the  epiphysis  are  described  on  pages  5T5 
and  589. 

The  symptoms  of  epiphyseal  separation  are  in  the  main  those  of  a 
fracture,  and  repair  takes  place  in  precisely  the  same  way.  AVe  have 
discussed  on  page  589  the  occurrence  of  disturbances  of  growth  after 
bony  consolidation  of  the  epiphyseal  line.  It  need  only  be  briefly 
stated  here  that  in  two  cases  of  suppurative  separation  of  the  upper 
epiphysis  of  the  tibia  in  comparatively  young  children,  Blasius  and 
A^olkmann  were  able  subsequently  to  demonstrate  no  shortening  after 
the  growth  of  the  body  had  been  completed. 

The  treatment  of  separations  of  the  epiphyses  is  conducted  accord- 
ing to  the  rules  which  govern  the  treatment  of  simple  and  compound 
fractures,  and  is  the  same  as  that  for  traumatic  separations,  which  was 
given  in  §  KU. 

§  108.  Rhachitis. — Ehachitis  (from  pa-x''^'  the  spine)  is  a  general  dis- 
turbance of  nutrition  which  occurs  in  early  childhood,  and  anatomically 
is  characterised  mainly  by  the  formation  of  bone  which  is  deficient  in 
lime,  and  by  an  increased  absorption  of  bone.  Therefore  the  bones 
affected  by  rickets  are  abnormally  soft  and  have  a  tendency  to  bend, 
to  suffer  infractions  ;  and  the  epiphyseal  cartilages  ai-e  remarkably 
thick — a  peculiarity  which  has  given  the  disease  the  name  of  doppeJte 
Glieder  (double  limbs).  Khachitis  is  a  disease  affecting  the  develop- 
ment of  bone,  and  a  true  disease  of  childhood,  most  commonly  begin- 
ning in  the  first  or  second  year  of  life,  very  rarely  after  the  fifth  or 
sixth.  According  to  Schwartz,  pronounced  rickets  is  often  observed 
in  infants,  and  the  investigations  of  Kassowitz  show  that  it  frequently 
begins  during  the  latter  months  of  foetal  life,  in  consequence  of  the 
transmission  of  morbid  stimuli,  or  as  a  result  of  deficient  absorption  of 
lime  from  the  maternal  circulation,  and  then  during  the  months  imme- 


§  108.] 


RIIACIUTIS, 


630 


(liiitely  following  birth  the  symptoms  of  the  affection  become  more  and 

more  marked.     In  the  Vienna  obstetrical  clinic,  among  five  hundred 

children,   Schwartz  found  80'6  per  cent,  to 

be  rhachitic,  and  the  great  majority  of  the 

mothers  of  these  rhachitic  children 

under  improper  dietetic  and  hygienic 

tions,  and  during  their  pregnancy 

hard  work.     Rhachitis  was   first  accurately 

described  l)y  the  English  surgeon  Glisson  in 

the  middle  of  the  eighteenth  century — hence 

the   name    "  English    disease " — but   it   was 

known  to  the  ancients. 

Anatomical  Changes  in  Rhachitis. — The 
anatomical  changes  in  rickets  have  recently 
been  studied  by  Yirchow,  Kassowitz^  Ba- 
ginsky,  and  others.  Kassowitz  ascribes  all 
the  manifestations  of  rhachitis  to  chronic  in- 
flammatory changes  at  the  boundary  line  be- 
tween the  foetal  and  infant  bone — i.  e.,  to  an 
abnormally  increased  vascularisation  of  the 
tissues  which  go  to  form  bone.  As  a  result 
of  this  hyperfemia,  and  the  numerous,  chiefly 
new-formed  vessels  at  the  epiphyses  in  the 
periosteum  and  medulla,  there  occurs  a 
growth  of  the  epiphyseal  cartilages,  a  dimin- 
ished deposit  of  lime  salts,  and  an  increased 
resorption  of  the  fully  formed  bone.  The 
bone  undergoes  a  lacunar  absorption  (Fig. 
343),  osteoclasts  being  present,  and,  as  I  have 
stated  before,  is  probably  dissolved  by  car- 
l>onic  acid.  Rhachitic  bone  is  poor  in  lime, 
and  the  newly  formed  bone  remains  for  a 
long  time  in  the  uncalcified  state.  Xot  till 
the  rhachitis  has  run  its  course  does  the 
ground  substance  of  the  bone  become  com- 
pletely calcifled,  and  then  usually  to  an  ex- 
treme degree,  so  that  the  affected  bone  ap- 
pears thickened  and  very  hard — sclerosed. 
The  changes  at  the  epiphyses  are  very  characteristic.  Under  normal 
conditions  the  epiphysis  is  defined  l)y  a  plain  white  line,  cartilage  and 
bone  being  sharply  differentiated  from  one  another.  But  in  rhachitis 
this  sharply  defined  linear  boundary  is  absent,  and  the  different  tissues, 


i 


Fig.  356.— Rhachitis.  Longitudi- 
nal -section  throuirh  the  upper 
epiphysis  of  tlie  tibia  near 
the  boundary  of  ossification ; 
a,  zone  of  the  proliferating 
columns  of  cartilage ;  h,  va.s- 
cular  medullary  spaces  in  the 
cartilage ;  e,  calcified  cartilag- 
inous tissue ;  d,  osteoid  un- 
calcified or  only  slightly  cal- 
cified tissue  with  remnants  of 
cartilaginous  tissue ;  e,  fully 
formed  bone. 


(340  INJURIES  AND   SUKGICAL   DISEASES  OF   BONE. 

the  cartilage,  bone  and  medulla,  appear  as  though  blended  together 
without  any  system  (Fig.  356).  The  cartilaginous  epiphyseal  line  is 
broadened  and  irregular,  the  boundary  between  cartilage,  bone,  and 
medullary  tissue  is  not  well  marked,  and  the  zone  of  calcilication  at  the 
points  of  ossification  is  absent  or  deficient.  The  most  important  fac- 
tors in  the  process  are  always'the  insufficient  deposit  of  lime  salts  and 
the  increased  absorption  of  the  bone  already  present.     Baginsky  states 

that  rhachitic  bone  has  lost  more  than  three 
fourths  of  the  lime  it  contains,  llhachitic 
bones  are  so  soft  that  they  can  easily  be  cut 
with  a  knife,  and,  in  consequence  of  this 
softness,  deformities  of  the  skeleton  occur. 
In  older  children  the  changes  in  the  thorax, 
the  vertebrfe  and  extremities  are  more  prom- 
inent than  those  in  the  skull.  Bow-shaped 
^  I  i     curves  develop  in  the  bones  of  the  extremi- 

ties, or,  more  commonly,  angular  deformi- 
ties at  the  ends  of  the  diaphyses  (Fig.  357) 
I  }        I        with    thickening    of    the    epiphyses.      The 

J         joints  are   loose,  abnormally  movable,  and 
painful.      At  the  knee  joint,  for  instance, 
y  ^   '^  "^^  there  is  very  often  a  considerable  abduction 

or  adduction  and  rotation  of  the  leg  in  con- 
sequence of  the  relaxation  of  the  ligaments 
Fig.  357.— Khacliitic  deformities    of  the   joint   and   the   rhacliitic   curvature 

which  exists  in  the  tibia  and  femur  (geim 
valgum  and  genu  varum  rhachiticum).  At  the  hip  joint  the  rhachitic 
bending  of  the  neck  of  the  femur  is  to  be  noted.  In  the  foot  the  so- 
called  "flat  foot"  develops,  etc.  This  relaxation  of  the  joints  and 
softness  of  the  bones  are  the  reasons  why  rhachitic  children  take  so 
long  to  stand  and  walk,  and  why  they  lose  their  ability  to  perform 
these  acts  in  recurrent  rhachitis  or  rhachitis  of  late  development.  The 
pelvic  walls  fall  together,  causing  the  cavity  to  become  contracted,  the 
promontory  of  the  sacrum  projects  downwards  and  forwards,  the 
acetabular  region  is  pushed  inwards,  the  symphysis  forwards.  Curva- 
tures develop  in  the  vertel)ra?  (scoliosis,  kyphosis),  and  the  thorax,  par- 
ticularly at  the  points  where  the  ribs  join  the  costal  cartilages,  becomes 
depressed,  so  that  in  severe  cases  the  sternum  is  pushed  forwards  (the 
so-called  "  chicken  breast,"  or  pectus  carinatum).  In  the  skull,  espe- 
cially in  the  occipital  region,  the  bones  remain  for  a  very  long  time 
soft  and  yielding  to  pressure,  and,  as  a  result  of  the  loss  of  bone  sub- 
stance, some  portions  may  again  become  membranous  (cranio-tabes  rha- 


§  108.]  RHACHITIS.  64-1 

chitica).  The  cutting  of  the  teeth  is  delayed,  and  after  the  disease  has 
been  cured  they  often  come  through  precipitately.  The  longitudinal 
growth  and  body  weight  are  less  than  they  normally  should  be.  I3ou- 
chat  states  that  rhachitic  children  only  grow  about  two  to  three  centi- 
metres in  a  year,  while  the  average  longitudinal  growth  in  health 
amounts  to  about  seven  to  eight  centimetres. 

Under  anomalies  of  internal  organs  are  to  be  mentioned  disturb- 
ances of  the  central  nervous  system  and  of  the  circulatory  and  digest- 
ive organs,  such  as,  for  example,  hypertrophy  or  sclerosis  of  the  brain, 
and  chronic  hydrocephalus.  The  spasm  of  the  glottis,  which  is  so 
common  in  rhachitic  children,  is  probably  caused  by  a  general  or  a 
reflex  anoemia.  Disturbances  of  digestion  (dyspepsia,  diarrhoea,  alter- 
nating with  constipation),  chronic  bronchitis,  lobular  pneumonia,  etc., 
are  very  common.  The  liver  is  very  often  decreased  in  size ;  the 
spleen,  on  the  other  hand,  is  usually  but  not  always  enlarged,  and 
sometimes  attains  enormous  dimensions.  The  skin,  mucous  mem- 
branes, lymph  glands,  etc.,  often  show  the  same  disturbances  of  nutri- 
tion as  in  scrofula  (see  page  423).  In  the  form  of  rhachitis  appearing 
somewhat  later  in  life  (rhachitis  tarda),  Levrat  (Lyon)  very  often  ob- 
served goitre. 

Analyses  of  the  urine  show,  according  to  Baginsky,  that  (1)  a  healthy 
child  retains  more  nitrogen  in  its  system  than  a  rhachitic  one,  and 
excretes  phosphoric  acid  more  freely  in  the  urine ;  (2)  that  under  the 
influence  of  dyspeptic  conditions  the  rhachitic  child  excretes  nitrogen 
in  the  urine  more  readily  than  the  healthy  child,  and  retains  phosphoric 
acid ;  (3)  that  no  difl:"erence  can  be  ihade  out  between  healthy  and 
rhachitic  children  as  regards  the  excretion  in  the  urine  of  lime  and 
magnesium ;  (4)  that  the  relative  amount  of  chlorine  excreted  in  the 
urine  of  healthy  children  is  greater  than  in  that  of  rhachitic  children. 
As  regards  the  excretion  of  phosphorus  or  phosphoric  acid  in  the 
urine  of  rhachitic  children,  the  statements  of  authorities  vary  very 
greatly ;  but  as  a  general  thing  the  majority  of  German  authorities 
declare  that  there  is  a  diminution  of  the  phosphoric  acid  in  the  urine 
(hypophosphouria)  in  rickets ;  while  the  majority  of  French  authori- 
ties maintain  that  there  is  an  increase  (hyperphosphouria). 

The  analysis  of  the  ash  of  the  fseces  shows  that  more  lime  is 
excreted  in  the  stools  of  rhachitic  children  (to  one  kilogramme  of  body 
weight)  than  is  normally  the  case,  and  that  the  excretion  of  phosphoric 
acid,  as  compared  with  that  in  health,  is  not  increased. 

The  Etiology  of  Rhachitis. — The  cause  of  rickets — which  we  have 
learned  to  recognise  as  a  general  disturbance  of  nutrition  in  children, 
mainly  localised  in  the  bony  system — has  been  made  the  object  of 
41 


642  INJURIES   AND   SURGICAL   DISEASES   OF   BONE. 

much  experimental  investigatiou.  The  majority  of  the  authorities 
ascribe  the  cause  of  rhachitis  to  malnutrition.  As  a  matter  of  fact,  we 
know  that  a  proper  supply  of  the  salts  of  the  alkalies  and  of  the  earthy 
salts  is  of  the  greatest  importance  for  the  nutrition  of  all  the  tissues. 
Chossat  and  others  have  demonstrated  by  experiments  on  young  grow- 
ing animals  that  by  feeding  them  with  food  deficient  in  lin:ie,  young 
birds  and  dogs,  for  example,  show  changes  which  are  analogous  to 
those  in  rhachitis.  Baginsky,  whose  careful  investigations  include  627 
cases  of  rickets  (347  boys  and  280  girls),  also  states  that  the  disease  is 
a  result  of  unfavourable  conditions  of  life,  especially  deficient  nourish- 
ment, bad  dwellings,  etc.  Rhachitis  is,  in  fact,  a  disease  of  the  poor, 
particularly  in  large  cities,  and  occurs  less  often  in  the  country,  as 
Morgan  and  Baxter  have  recently  proved  by  extensive  statistics.  Bill- 
roth and  Winiwarter  maintain  that  in  Vienna  about  eighty  per  cent,  of 
the  children  of  the  poorer  classes  show  symptoms  of  rickets.  Children 
who  are  brought  up  by  bad  artificial  feeding  without  being  nursed  at 
the  breast,  and  who  have  disorders  of  digestion,  are  particularly  apt  to 
be  affected  with  rickets.  According  to  R.  L.  Lee,  preceding  respira- 
tory disturbances  due  to  bronchitis,  pneumonia,  whooping-cough,  etc., 
are  also  of  great  etiological  importance.  Furthermore,  we  saw  on 
page  629  that  the  syphilitic  poison,  and  possibly  also  other  haematoge- 
nous  dyscrasiae,  excite  changes  at  the  epiphyseal  junctions  which  are 
similar  to  those  of  true  rhachitis ;  and  doubtless  rickety  children  suffer 
from  hereditary  syphilis  more  often  than  is  generall}^  supposed. 

The  Course  of  Rhachitis  is  for  the  most  part  chronic,  more  rarely 
acute,  and  the  earlier  the  rhachitis  occurs  the  more  rapid,  as  a  general 
thing,  is  its  course.  Thus  the  rare  cases  of  congenital  rickets  run  a 
very  rapid  course ;  and  of  the  children  affected  by  the  disease  during 
the  months  immediately  following  birth,  a  large  part  perish  from  in- 
creasing inanition  due  to  unfavourable  hygienic  conditions.  But  if 
the  causative  factors  are  removed,  and  the  children  properly  fed  and 
their  surroundings  improved,  the  disease  usually  disappears  rapidly — 
in  the  milder  cases  within  five  to  six  months,  and  in  the  more  severe 
ones  within  two  to  three  years.  Occasionally  the  disease  drags  on  till 
the  fifth  or  sixth  year ;  cases  lasting  longer  than  this  are  very  rare.  In 
the  cases  of  acute  rhachitis  there  are  sometimes  complicating  disturb- 
ances of  nutrition,  particularly  scurvy,  which  may  occur  simultaneously 
with  the  rickets  (Th.  Smith,  Barlow,  etc.). 

The  Diagnosis  of  Rhachitis,  as  a  rule,  is  very  easy,  for  the  reason  that 
the  above-described  anatomical  changes  in  the  skeleton  are  pathogno- 
monic. It  should  be  a  rule,  in  making  an  examination,  to  undress  com- 
pletely all  children  suffering  from  chronic  disease. 


^W8.]  RHACHITIS.  G43 

The  Prognosis,  if  proper  treatment  is  adopted,  is  favourable,  as  we 
have  said  before.  J>ut  if  the  unfavourable  conditions  continue,  a  large 
proportion  of  rhachitic  children  perish  from  diseases  of  the  intestinal 
tract,  of  the  respiratory  organs,  from  hydrocephalus,  general  inanition, 
etc. 

The  Treatment  of  Rhachitis  consists,  in  the  first  ]:)lace,  in  the  ad- 
ministration of  proper  food  to  the  child,  and  in  doing  away  as  soon  as 
possible  with  all  unfavourable  hygienic  conditions.  Inasmuch  as  recent 
investigations  show  that  rhachitis  is  of  such  common  occurrence  in 
young  infants,  they  must  always  be  carefully  examined  for  its  presence, 
and  in  cases  where  the  disease  is  found  the  proper  treatment  must  be 
begun  early.  The  best  food  for  suckling  children  is  mothers'  milk  or 
good  cows'  milk  sterilised  by  Soxhlet's  apparatus.  Nursing  the  child 
longer  than  the  first  year  of  its  life,  Baginsky  states,  is  just  as  apt  to 
cause  rickets  as  is  the  administration  at  too  early  a  period  of  starchy  or 
indigestible  food.  All  disorders  of  digestion  and  other  complications 
in  rhachitic  children  should  be  carefully  treated  according  to  the  gen- 
eral rules  which  apply  to  them.  Internally,  cod-liver  oil,  iron,  lime, 
phosphorus,  arsenic,  and  pyrogallic  acid  have  been  recommended  for 
rhachitis,  but  in  their  administration  the  state  of  the  digestive  organs 
must  be  taken  into  consideration.  Cod-liver  oil,  which  may  be  com- 
bined with  extract  of  malt,  is  useful  for  children  who  are  not  fat,  espe- 
cially in  winter.  Lime  is  given  in  the  form  of  liquor  calcis  added  to 
milk,  or  in  a  mixture  made  of  carbonate  and  phosphate  of  calcium  with 
ferri  oxyd.  sacch.  (ferri  carb.  sacch.),  equal  parts  of  each,  enough  to 
cover  the  point  of  a  knife,  three  times  a  day.  On  account  of  its  osteo- 
plastic action  the  administration  of  phosphorus  has  recently  been 
recommended  for  rhachitis  by  Wegner  and  Kassowitz.  It  is  given 
(1  milligramme  j9r(9  die)  in  cod-liver  oil  (0-01  gramme  phosphor.,  1000- 
cubic  centimetres  ol.  morrhuse,  one  to  two  teaspoonfuls  a  day),  or  in 
pill  form  with  oil  of  phosphorus  and  some  indifferent  powder  enclosed 
in  gelatine  capsules.  Maas  and  others  maintain  that  arsenic  and  pyro- 
gallic acid  have  also  an  osteoplastic  action  like  phosphorus.  Three  per 
cent,  brine  baths,  sea  baths,  health  resorts  situated  on  high  land,  and 
proper  climate  have  as  valuable  an  influence  upon  rickets  as  they  have 
upon  scrofula  (see  page  424).  To  prevent  as  far  as  possible  the  curva- 
tures and  angular  deformities  which  may  occur  in  the  extremities,  for 
example,  rhachitic  children  should  not  be  encouraged  to  stand  and  walk 
at  too  early  a  period.  Braces  and  similar  apparatus  should  be  used  to 
support  the  lower  extremities,  and  the  application  of  light  water-glass 
or  starch  dressings  is  also  advantageous.  After  the  rhachitis  has  sub- 
sided, the  bony  deformities,  particularly  those  in  the  leg,  often  have  to 


64:4 


INJURIES  AND  SURGICAL   DISEASES   OP   BONE. 


be  corrected,  the  crooked  boues  either  being  broken  bj  hand  or  by  Riz- 
zoh's  osteoclast  (Fig.  Y4,  page  84),  and  then  when  thej  have  been  ren- 
dered straight  treated  like  a  subcutaneous  fracture.  In  other  cases, 
when  the  strength  and  sclerosis  of  the  bone  is  considerable,  it  will  be 
impossible  to  break  the  bone  subcutaneouslj,  and  subcutaneous  oste- 
otomy, combined  possibly  with  an  excision  of  a  wedge-shaped  piece  of 
bone,  must  be  undertaken.  To  perform  osteotomy,  the  proper  incision 
is  made  through  the  skin,  and  through  this  the  bone  is  divided  with 
the  hammer  and  chisel,  with  the  exception  of  a  small  portion  of  the  cor- 
tex, which  is  then  usually  broken  by  hand.  The  wound  is  not  sutured, 
and  after  covering  it  with  an  antiseptic  protective  dressing  a  plaster-of- 
Paris  splint  is  immediately  applied.  If  the  operation  is  carried  out  with 
antiseptic  precautions  it  is  entirely  devoid  of  danger.  Macewen's  oste- 
otomy at  the  lower  end  of  the  diaphysis  of  the  femur  is  also  very  ap- 
propriate in  cases  of  genu  valgum  rhachiticum.  Tenotomy  of  the 
tendo  Achilles  must  sometimes  be  added  when  the  curvature  of  the 
tibia  is  convex  anteriorly.  But  frequently  braces  will  be  sufhcient  to 
overcome  deformity,  the  bones  gradually  becoming  straight  of  their 
own  accord.  I  must  refer  the  reader  to  my  Special  Surgery  for  the 
particulars  of  the  treatment  for  the  various  sequelae  of  rhachitis  in 
the  diiferent  portions  of  the  body,  such  as  the  vertebrae,  the  extremi- 
ties, etc. ' 

§  109.  Osteomalacia. — By  osteomalacia  we  understand  a  peculiar 
softening  and  resorption  of  bone  substance  which  is  observed  most 
commonly  in  women  during  pregnancy  and  the  puerperium,  less  often 


Fig.  358.— Osteomalacia  (pelvis).     Trabeculse  of  decalcilied  bone  with  remnants  of  calcified  bone. 
The  enlarged  medullary  spaces  (M)  have  arisen  from  absorption  of  the  trabecule,     x  75. 

in  men,  and  in  women  who  are  not  pregnant.  The  disease  not  in- 
frequently occurs  in  pregnant  and  milch  cows.  In  osteomalacia  the 
normal,  strong  bones  of  adults  become  soft,  while  in  -rhachitis,  on  the 
other  hand,  we  have  to  deal  with  a  disease  of  development  affecting 


§  109.]  OSTEOMALACIA.  645 

young  bone,  in  consequence  of  which  the  hitter  remain  soft  and  do  not 
become  firm. 

Anatomical  Changes  in  Osteomalacia.— The  pueri)eral  form  of  osteoma- 
lacia probably  always  bofjins  in  the  pelvis,  and  either  remains  limited  to  the 
latter  or  attacks  other  bones,  and  may  even  involve  most  of  the  skeleton, 
particularly  if  the  woman  passes  through  several  pregnancies  after  the  ap- 
pearance of  the  disease.  The  non-puerperal  form  begins  most  commonly  in 
the  vertebris  and  thorax,  and  then  extends  to  the  extremities  and  finally  to 
the  bones  of  the  head.  The  softening,  the  absorption  of  bone  substance 
(Fig.  358),  is  an  halisteresis — i.  e.,  the  lime  salts  are  first  dissolved,  but  the 
decalcified  ground  substance  persists  a  little  while  longer,  then  it  also  gradu- 
ally disintegrates,  and  is  fipally  absorbed.  The  absorption  of  the  lime  salts 
always  begins  in  the  periphery  of  the  bone  and  advances  steadily  towards 
the  centre.  In  this  manner  a  considerable  loss  of  bone  may  be  brought 
about,  and  the  cortex  of  the  long  bones  may  become  as  thin  as  paper,  or  the 
diseased  bone  may  even  entirely^  disappear,  leaving  only  the  periosteum 
and  medulla  to  persist  as  an  elastic  tube.  Morand  observed  a  very  pro- 
nounced degree  of  osteomalacia  in  a  woman  who  possessed  in  the  place  of 
most  of  her  bones  only  membranous  cylinders  or  very  thin  tubes  of  bone. 
In  the  milder  cases,  which  recover  quickly,  the  decalcified  bone  substance 
can  be  very  rapidly  changed  to  normal  bone  by  a  fresh  deposit  of  the  salts 
of  lime.  As  long  as  the  disease  is  advancing  the  medulla  is  usually  very 
richly  supplied  with  blood,  contains  numerous  hsemorrhagic  foci  scattered 
through  it,  has  an  abundance  of  cells,  and  is  poor  in  fat.  In  rare  instances 
of  osteomalacic  softening  of  bone  there  have  been  noted  multiple  cystic  for- 
mations with  tumour-like  enlargement  of  the  softened  portions  of  bone  (Al- 
bertin).  There  are,  moreover,  cases  which  present  the  clinical  picture  of 
osteomalacia,  and  anatomically  are  due  to  the  development  of  multiple  true 
tumours,  especially  sarcomata  (Recklinghausen).  As  a  result  of  the  softening 
of  the  bones  there  of  course  arise  corresponding  curved  or  angular  deformi- 
ties, and  fractures.  Changes  of  shape  in  the  osteomalacic  pelvis  are  particu- 
larly common.  Recklinghausen  and  Rehn  have  recently  described  an  in- 
fantile osteomalacia,  but  this  is  probably  in  the  main  a  severe  rhachitis. 

The  Etiology  of  Osteomalacia. — Tlie  precise  cause  of  osteomalacia  is 
still  but  little  understood,  though  various  theories  have  been  advanced. 
We  only  know  that  it  occurs  chiefly  in  pregnant  or  nursing  women 
and  animals,  and  is  common  in  certain  regions  w^hicli  in  Germany  lie 
along  the  Rhine,  while  other  places,  like  the  valley  of  the  Oder,  appear 
to  be  free  from  it.  Damp,  unhealthy  dwellings,  malaria,  anaemia,  and 
other  constitutional  anomalies  connected  with  disturbances  of  nutrition, 
are  said  to  be  of  importance.  Cohnheim  maintains  that  osteomalacia, 
like  rhachitis,  is  a  disturbance  of  nutrition,  and  he  believes  that  the 
maternal  organism  during  pregnancy  and  the  nursing  period  contains 
too  little  lime,  because  a  very  large  amount  of  lime  salts  are  necessary 
for  the  development  of  the  foetal  skeleton  as  well  as  for  the  milk.     For 


tJ46  INJURIES  AND    SURGICAL   DISEASES  OF  BONE. 

this  reason  only  osteoid  tissue,  which  is  deficient  or  entirely  lacking  in 
lime,  is  formed  in  the  maternal  organism.  Consequently,  according  to 
Cohnheim's  theory,  the  uncalcified  or  deficiently  calcified  bone  tissue 
is  not  decalcified  old  bone  tissue,  but  new-formed  osteoid  tissue.  I  be- 
lieve, however,  that  the  old  idea  is  correct,  viz.,  that  the  bone  tissue 
which  is  poor  in  lime  or  in  which  the  lime  is  absent  is  the  decalcified 
ground  substance  of  the  old  bone.  It  is  natural  that  the  cause  for  the 
decalcification  in  this  condition  should  also  be  ascribed  to  an  acid  such 
as  lactic  acid,  or,  more  correctly,  carbonic  acid  ;  but  as  yet  no  proof  of 
this  has  been  obtained.  Heiss  and  others  have  fed  animals  with  lactic 
acid  for  months  (three  hundred  and  eight  days,  for  example),  and  yet 
have  not  been  able  to  produce  osteomalacia.  It  seems  more  probable 
that  the  decalcification  is  due  to  the  action  of  carbonic  acid  ;  it  is  pos- 
sible, and  the  hypereemia  of  the  medulla  favours  this  view,  that  in 
Osteomalacia  we  have  to  deal  with  an  inflammatory  process  accom- 
panied by  an  increased  vascularity  and  an  abnormal  formation  of  car- 
bonic acid.  Examination  of  the  urine,  however,  does  not  always  show 
an  increased  excretion  of  earthy  phosphates,  a  thing  which  the  acid 
theory  would  lead  us  to  expect.  Petrone  calls  attention  to  the  in- 
creased amount  of  nitric  acid  contained  in  the  urine,  and  believes  that 
osteomalacia  is  caused  by  the  micro-organism  described  by  Schlussing 
and  Miinz,  which  produces  nitric  acid.  In  one  case  of  non-puerperal 
osteomalacia  observed  by  Kobler,  with  pronounced  changes  in  almost 
all  the  bones,  examination  of  the  ash  obtained  from  the  blood  revealed 
a  considerable  increase  of  sulphuric  acid  and  a  diminution  of  the  so- 
dium to  less  than  half  the  normal  quantity.  The  rare  osteomalacia  of 
men,  and  of  women  who  are  not  pregnant  or  nursing,  depends,  accord- 
ing to  Cohnheim,  in  the  main  upon  disorders  of  digestion  or  of  as- 
similation, combined  with  a  lessened  absorption  of  lime. 

We  have  practically  given  the  symptomatology  of  osteomalacia  in 
the  above  description.  The  disease  almost  always  begins,  as  we  have 
said,  during  pregnancy  or  during  the  puerperium,  with  severe  shooting 
pains  in  the  affected  bones.  Consequently  the  disease,  at  the  outset,  is 
often  confused  with  rheumatism,  until  the  changes  in  the  shape  of  the 
_bones  enable  the  correct  diagnosis  to  be  made.  The  affection  may  be- 
come very  pronounced  during  a  single  pregnancy  or  a  single  puer- 
perium. The  milder  cases  will  get  entirely  well ;  but  very  frequently 
the  disease  makes  pauses  in  its  progress,  and  then,  in  conjunction  with 
another  pregnancy,  though  apparently  cured,  it  will  break  out  again 
with  fresh  intensity.  Recklinghausen  observed  osteomalacia  in  young 
subjects  in  combination  with  Basedow's  disease. 

The  prognosis  of  osteomalacia  is  very  unfavourable,  and  actual  cures 


§110.]  ATROPHY    AND   HYPERTROPHY   OF   BONE.  647 

are  exceedingly  rare.  Nevertlieless,  the  operative  removal  of  the 
ovaries  in  puerperal  osteomalacia,  recently  recommended  by  Fehling, 
yields  surprisingly  good  results. 

The  treatment  of  osteomalacia  is  like  that  of  rickets  (see  pages  643, 
644),  and  consists  primarily  in  the  administration  of  good  nutritious 
food,  also  cod-liver  oil,  iron,  lime,  quinine,  phosphorus,  and  arsenic. 
All  iinfavourable  hygienic  conditions,  disturbances  of  nutrition,  and 
constitutional  anomalies  are,  as  far  as  possible,  to  be  done  away  with. 
If  the  woman  is  nursing  her  child,  she  must  be  forbidden  to  do  so,  and 
made  aware  of  the  danger  that  in  a  new  pregnancy  the  disease  may 
recur  with  increased  severity.  Great  interest  attaches  to  the  cures  of 
osteomalacia  recently  obtained  by  the  removal  of  the  ovaries.  The 
castration,  which  was  first  recommended  by  Fehling,  is  either  per- 
formed by  itself,  or  combined  with  Porro's  supravaginal  removal  of  the 
gravid  uterus.  The  success  of  this  procedure  is  so  remarkable  that  pa- 
tients with  a  very  pronounced  form  of  the  disease  can  be  cured  and 
allowed  to  attend  to  their  employment  after  the  lapse  of  from  three  to 
four  to  five  weeks.  Petrone  believes  that  the  success  is  mainly  to  be 
ascribed  to  the  narcosis  and  not  to  the  operation,  as  he  has  cured  one 
case  of  osteomalacia  in  three  weeks  by  the  daily  administration  of  two 
grammes  of  chloral  hydrate,  the  nitric  acid  which  was  present  in  the 
urine  disappearing  on  the  fifth  day  of  the  treatment. 

The  castration  recommended  by  Fehling  for  osteomalacia,  with  or 
without  supravaginal  removal  of  the  uterus,  deserves  the  most  general 
consideration  because  of  the  success  which  has  already  been  obtained. 
We  must  not  omit  to  state  that  in  rare  instances  the  osteomalacia  of 
women  also  gets  well  spontaneously. 

§  110,  Atrophy  and  Hypertrophy  of  Bone. — Atrophy  of  bone  is  due 
to  various  causes.  Every  resorption  of  fully  formed  bone  substance, 
which,  as  we  have  seen,  occurs  so  frequently  under  pathological  condi- 
tions, is  to  be  looked  upon  as  an  atrophy  of  bone.  The  resorption  of 
bone  substance  either  takes  place  on  the  external  surface  of  the  bone  or 
it  starts  in  the  medulla  and  advances  outwards.  In  the  outer  (concen- 
tric) atrophy  the  bone  becomes  smaller  and  thinner,  while  in  the  case 
of  the  internal  (excentric)  atrophy  the  medullary  cavity  and  the  Haver- 
sian canals  grow  larger  and  the  bone  becomes  porous  (osteoporosis). 

The  senile  atrophy  which  affects  the  bones  of  the  skull  (the  cranial 
vault,  the  inferior  maxilla,  etc.)  and  of  the  extremities,  especially  their 
articular  ends,  is  a  special  form  of  bone  atrophy.  The  senile  osteo- 
porosis of  the  neck  of  the  femur  is  of  practical  importance,  as  the  neck 
gradually  becomes  depressed  and  may  be  broken  by  a  very  slight 
traumatism. 


648 


INJURIES  AND   SURGICAL  DISEASES   OF   BONE. 


A  common  cause  of  the  atrophy  of  a  bone  is  disuse  of  the  latter 
(atrophy  of  disuse).  We  have  said  tliat  this  follows  paralyses,  inflam- 
mations of  joints,  temporary  immobilisation  of  an  extremity  by  a  plas- 
ter-of-Faris  dressing,  etc.    The  disappearance  of  the  acetabulum,  which 

occurs  when  a  dislocation  of  the  hip  is  not  re- 
duced, also  belongs  to  the  atrophies  of  disuse. 
This  form  of  atrophy  may  take  place  in  cer- 
tain limited  portions  of  a  bone,  as  in  the  callus 
formed  after  a  fracture,  those  portions  of  the 
bone  substance  gradually  disappearing  which 
have  become  useless  for  the  function  of  the 
bone. 

Another  form  of  atrophy  of  bone  is  the 
neuroparalytic  and  trophoneurotic,  which  oc- 
curs in  conjunction  with  diseases  of  the  nerv- 
ous system,  such  as  tabes,  or  as  a  result  of 
changes  in  the  trophic  nerve  fibres  or  afferent 
nerves,  or  in  the  trophic  centres  in  the  anterior 
horns  of  grey  matter  in  the  spinal  cord  (Fig. 
359).  A  careful  description  of  the  trophoneu- 
rotic diseases  of  the  bones  and  joints  is  given 
in  §  117. 

Local  arrest  of  longitudinal  growth  is 
caused  by  diseases  of  the  epiphyseal  cartilages, 
such  as  inflammation  or  suppuration,  or  it 
may  follow  their  ossiflcation  at  too  early  a 
period  or  their  removal  in  too  extensive  a 
resection,  etc.  Fressure,  inflammation,  and 
the  development  of  a  tumour  may  also  lead  to 
localised  atrophy,  to  wearing  away  of  bone,  or 
to  caries. 

Hypertrophy  of  Bone  is  either  limited  to 
some  particular  portion  of  a  bone,  as  in  the 
formation  of  osteophytes,  or  it  affects  the  en- 
tire bone,  the  whole  volume  of  the  latter  being  increased  or  only  its 
length  or  thickness.  The  hypertrophies  include  the  hyperostoses  men- 
tioned on  a  previous  page — i.  e.,  the  increase  in  volume  following  peri- 
osteal and  endosteal  formation  of  bone,  and  the  osteosclerosis  or  thick- 
ening of  bone  tissue,  which  is  also  called  eburneatio  ossis. 

Helferich  and  others  have,  as  we  remarked  before,  increased  the 
development  of  bone  at  a  given  point  by  artificial  hypersemia,  pro- 
duced, for  example,  by  tying  off  the  extremity  with  an  elastic  tourni- 


Fio.  359.— Partial  (tropho-neu- 
rotic  ?)  atrophy  of  the  skele- 
ton (upper  part  of  the 
body)  ;  pelvis  and  lower 
extremities  are  well-devel- 
oped ;  thirty-five-year-old 
unmarried  woman  (Mosen- 
geil). 


§110.] 


ATROPHY   AND   HYPERTROPHY  OF   BONE. 


649 


Fig.  360. — Partial  giant  growth 
on  the  hand  (Curling  and 
Bohm). 


quet  drawn  moderately  tight  on  the  proximal  side  of  the  point  in  the 
bone  which  is  diseased.     This  procedure  is  worth  trying  in  the  case  of 
fractures  where  the  callus  formation  is  de- 
layed and  insufficient,  and  in  pseudarthrosis, 
and    also    to   diminish    shortening,    etc.   (see 
page  603). 

The  lengthening  which  bones  mav  under- 
go  in  conjunction  with  irritation  of  the  epi- 
physeal cartilages  due  to  injuries  and  diseases 
of  the  diaphysis  or  neighbouring  joints  and 
soft  parts,  is  also  a  matter  of  practical  impor- 
tance. As  Oilier  has  demonstrated  experi- 
mentally, an  increase  in  the  longitudinal 
growth  of  young  bones  is  very  easily  brought 
about  by  stimuli  of  various  kinds.  This  ex- 
plains the  occurrence  of  the  increased  longi- 
tudinal growth  which  takes  place  in  conjunction  with  fractures,  espe- 
cially those  which  are  compound  and  heal  with  marked  inflammatory 
reaction,  or  which  follows  necrosis,  osteomyelitis,  large  ulcers  of  the 
foot,  and  diseases  of  joints.  Young  bones  which  have  been  dislocated 
and  not  replaced  take  on  increased  longi- 
tudinal growth  if  they  are  freed  from  the 
pressure  of  the  superimposed  bone.  Thus, 
for  example,  increased  longitudinal  growth 
of  the  radius  takes  place  after  dislocation 
of  its  head. 

Congenital  hypertrophy  of  bone  makes 
its  appearance  in  the  form  of  giant  growth 
of  the  fingers  and  toes  (Fig.  360,  macro- 
dactylia),  and  also  as  giant  growth  of  an 
entire  extremity  (Figs.  361,  362).  Ac- 
cording to  Wittelshofer's  statistics,  all  the 
cases  of  true  giant  growth  hitherto  re- 
corded are  congenital  in  origin,  and  origi- 
nate, as  in  the  case  of  the  very  considera- 
ble monstrosity  illustrated  in  Figs.  361 
and  362,  from  an  abnormal  increase  of 
growth  involving  all  the  tissues  of  one 
part  of  the  body.  Giant  growth  is 
possibly  a  congenital  trophoneurotic   disturbance. 

The  cases  of  acquired  hypertrophy  of  the  bones  and  soft  parts 
(compensatory  hypertrophy)  are,  of  course,  to  be  distinguished  from 


Fig.  361. — Giant  growth  of  the  upper 
extremity  and  the  right  side  of 
the  thorax  (Wagner). 


650 


INJURIES  AND   SURGICAL   DISEASES   OP  BONE. 


this  congenital  giant  growth.  P.  Wagner  has  recently  collected  several 
cases  of  congenital  and  acquired  giant  growth,  and  has  given  the  litera- 
ture on  this  subject  (Zeitschrif t  f  iir  Chir.,  Bd.  xxvi,  page  216).  Bessel- 
Hagen  has  called  attention  to  the  various  anomalies  of  the  bones  and 
joints  which  occur  in  giant  growth. 

As  regards  the  treatment  of  partial  giant  growth,  elastic  bandaging, 
massage,  and  Weir  Mitchell's  cure  have  been  used  with  success  in  the 


Fig.  362. — Giant  growth  of  the  lower  extremity  on  the  right  side,  and  the  upper  extremity  on  the 

left  side. 

milder  forms  of  the  affection.  In  severe  cases,  which  cause  much  trou- 
ble in  consequence  of  the  awkwardness  and  weight  of  the  aft'ected 
extremity,  operative  measures  will  sometimes  be  necessary,  and  the 
enlarged  member  should  be  removed  (see  also  Treatment  of  Elephan- 
tiasis). 

Acromegaly,  a  disease  to  which  Marie,  in  1886,  first  directed  atten- 
tion, must  be  carefully  distinguished  from  the  congenital  giant  growth. 
In  acromegaly,  which  begins  about  the  tenth  to  the  twentieth  to  the 
thirtieth  year  of  life,  and  lasts  ten  to  twenty  years  or  longer,  there  is 
a  hypertrophy  of  all  parts  of  the  body,  involving  both  the  bones  and 
the  soft  parts,  especially  of  the  head  and  extremities.  The  hands  and 
feet  have  the  appearance  of  paws.  In  the  head  the  hypertrophy  af- 
fects most  commonly  the  lower  jaw,  tongue,  nnder  lip,  and  nose.  The 
power  of  vision  may  be  completely  lost,  owing  to  the  pressure  exei'ted 
by  the  enlarged  sphenoid  bone  on  the  optic  nerve.  Hadden  and 
Ballame  state  that  the  disturbance  of  sight  is  caused  by  compression 
of  the  optic  chiasm  or  medullary  stride  of  the  optic  nerve  brought 
about  by  the  hypertrophy  of  the  pituitary  body.  The  vertebrae,  ster- 
num, and  ribs  are  symmetrically  enlarged  ;  there  are  kyphotic  curv- 
atures of  the  spinal  column  ;  the  joints  are  deformed  ;  the  internal 
organs,   brain,    muscles,    nerves,    etc.,    hypertrophy.     The    subjective 


gllO.J  ATROPHY    AND    II YPRRTROPUY   OF   BONE,  051 

symptoms  jircsoiitod  arc  pains  in  the  liead  and  joints,  a  feeling  of 
weakness,  and  paraesthesia.  A  steadily  increasing  cachexia  iinally 
makes  its  appearance.  The  precise  cause  of  acromegaly  is  still  ob- 
scure. According  to  W.  A.  Freund,  the  affection  is  an  anomaly  of 
growth,  and  he  believes  tliat  its  immediate  cause  must  be  ascribed  to 
an  increased  flow  of  blood  to  the  dilated  vessels.  Inherited  predisposi- 
tion to  the  disease  is  contested  by  some  authorities  and  accepted  by 
others.  It  probably  has  a  complex  etiology,  and  occurs  after  various 
kinds  of  disorders,  including  tumours  of  the  brain,  for  example.  Great 
psychical  excitement  has  frequently  been  thought  to  be  the  primary 
cause  of  the  affection. 

Acromicria. — The  condition  the  reverse  of  acromegaly  is  called  acromicria 
(Stembo,  Reidel).  In  this  there  is  a  striking  atrophy,  especially  of  the  ter- 
minal portions  of  the  body  (head,  fingers,  toes),  together  with  a  process  of 
shrinkage,  which  attacks  different  organs  and  sometimes  the  entire  body. 
The  etiology  of  the  affection  is  very  obscure,  and  the  disease  must  be  care- 
fully differentiated  from  syringomyelia,  Morvan's  disease,  the  anaesthetic 
form  of  leprosy,  Raynaud's  disease,  and  from  analogous  syphilitic  or  dia- 
betic affections  of  the  fingers.  According  to  Stembo,  the  disease  begins  on 
the  fingers.  On  the  latter  there  is  often  a  development  of  blebs  or  ulcers, 
which  heal  slowly,  and  are  accompanied  by  intermittent  pain.  The  skin  on 
the  fingers  grows  more  and  more  thin,  cicatricial,  and  tense;  all  the  nails 
perish,  the  fingers  become  shorter  and  less  movable,  and  the  entire  body 
grows  smaller,  from  atrophy  of  the  skin  and  the  soft  parts,  including  the 
tongue  and  oesophagus.  The  face  assumes  a  peculiar  stiff,  immovable,  and 
bird-like  exj)ression.  There  are  no  disturbances  of  sensibility,  the  cutaneous 
reflexes  are  normal,  the  tendon  reflexes  diminished,  and  the  electrical  ex- 
citability of  the  muscles  and  nerves  is  slightly  increased. 

Daily  Variations  in  Height.— As  regards  the  well-known  fact  that  man 
becomes  shorter  in  the  course  of  the  day,  Merkel  has  made  some  accurate 
measurements  (mostly  upon  himself),  and  has  found  that  the  length  of  the 
body  in  the  morning  in  the  recumbent  position,  immediately  after  awaken- 
ing, is  some  five  centimetres  more  than  in  the  evening  in  the  erect  position. 
The  loss  in  size  is  partly  gradual  and  partly  sudden.  The  former  is  due  to 
the  gradually  increasing  compression  of  the  sole  of  the  foot  and  the  inter- 
vertebral fibro-cartilages ;  while  the  latter,  or  sudden  diminution  of  stature 
on  rising  from  the  horizontal  to  the  perpendicular  position,  is  brought  about 
by  compression  of  the  joints  of  the  lower  extremity,  a  shortening  of  eight 
millimetres  taking  place  in  the  region  of  the  ankle  joint,  of  two  to  three 
millimetres  at  the  knee,  and  of  one  centimetre  at  the  hip.  This  lessening  of 
the  length  of  the  lower  extremities  is  mainly  caused  by  compression  of  the 
elastic  articular  cartilages  and  by  the  sinking  of  the  caput  femoris  into  the 
cavity  of  the  acetabvdum,  which  occurs  upon  standing  in  the  erect  position. 

Lymphadenia  Ossium  (Nothnagel). — A  peculiar  kind  of  pernicious  bone 
disease,  which  has  been  described  by  Nothnagel,  requires  mention  at  this 
point.     It  was  observed  in  a  man  twenty-four  years  of  age,  and  terminated 


652  INJURIES  AND  SURGICAL   DISEASES   OF   BONE. 

fatally  in  a  year  and  a  half,  the  patient  having  been  afflicted  with  severe 
pains,  thickening  of  the  bones,  and  steadily  increasing  cachexia.  The  autopsy 
revealed  a  very  extensive  development  of  a  lymphadenoid  tissue,  with  a 
great  number  of  Charcot-Neumann  crystals  in  the  bones,  and  at  the  same 
time  a  periosteal  and  medullary  new  formation  of  bone.  The  medulla  had 
almost  comj)letely  disappeared.  Nearly  all  the  bones  were  diseased,  the 
phalanges  of  the  hands  and  feet  and  the  bones  of  the  face  alone  remaining 
unaffected.  The  lymph  glands  and  the  spleen  were  enlarged,  probably  to 
compensate  for  the  lack  of  medullary  tissue,  with  its  power  of  making  blood. 

§  111.  The  Tumours  of  Bone. — The  tumours  peculiar  to  bone  (os- 
teoma, exostosis,  osteosarcoma,  enchondroma,  soft-boiie  tumours,  cjst, 
etc.)  will  be  described  in  §§  125-130,  where  we  shall  take  up  the  sub- 
ject of  tumours  in  general.  At  present  we  shall  only  briefly  discuss 
the  parasitic  tumours  of  bone. 

Of  animal  parasites  there  occur  in  bone  the  echinococcus  and  the 
cysticercus  cellulosoe,  the  latter  being  very  rarely  met  with.  Volk- 
mann  mentions  one  case  of  Froriep's,  in  which  this  parasite  was  found 
in  the  first  phalanx  of  the  middle  finger,  the  symptoms  being  those  of 
a  panaritium  periostale. 

Of  echinococcus  of  bone  there  are  fifty  known  cases. 

EcMnococcus  of  Bone. — The  taenia  echinococcus,  as  is  well  known,  is  a 
four-jointed  parasite  about  four  millimetres  long,  which  lives  in  the  intesti- 
nal canal  of  the  dog;  and  only  the  cysticercus  of  this  taenia,  after  the  intro- 
duction of  the  taenia  eggs  into  the  intestinal  canal,  occurs  in  man.  In 
whatever  organs  the  embryo  lodges,  the  liver  being  the  one  most  commonly 
affected,  characteristic  cystic  tumours  develop.  The  cyst  is  made  up  of  a 
lamellar,  very  elastic  cuticular  layer  (ectocyst),  on  the  inner  surface  of  which 
is  a  granular  parenchymatous  layer.  From  this  inner  layer  the  so-called 
brood-capsules  develop,  and  upon  these  are  formed  the  scolices  in  great 
numbers.  The  echinococcus  cyst  either  remains  single— unilocular — or  it  goes 
on  to  form  daughter  cysts  by  exogenous  and  endogenous  proliferation.  The 
size  of  the  cysts,  especially  in  the  liver,  is  often  very  considerable.  The 
echinococcus  multil ocularis  is  another  form  of  the  echinococcus,  which 
forms  in  the  liver  only  small  cysts  in  great  numbers,  varying  from  the  size 
of  a  millet  grain  to  that  of  a  pea,  which  are  surrounded  by  a  thick,  tough, 
diffuse  mass  of  connective  tissue. 

The  echinococcus  cysts  excite  a  local  inflammation  which  leads  to  the 
formation  of  a  connective-tissue  capsule.  The  cysts,  after  attaining  the  size 
of  a  walnut  or  apple,  often  die,  and  their  fluid  contents  become  absorbed,  a 
cheesy,  fatty  detritus  or  calcification  being  then  found  inside  the  shrunken 
sac.  In  other  instances  the  cysts  grow  so  large  as  to  become  dangerous,  and 
by  penetrating  or  bursting  into  some  cavity  of  the  body  give  rise  to  severe 
inflammations. 

The  ecliinococcus  develops  in  bone,  especially  in  the  medulla  (Fig. 
363),  and  occasionally  forms  at  some  point  where  the  bone  has  been  sub- 


^111.] 


THE  TUMOURS  OF   BONE. 


653 


jeeted  to  a  traumatism.  The  echinococcus  cysts  of  bone  are  of  slow, 
indolent  c^rowth,  and  after  the  la})se  of  years  sometimes  give  rise  to 
painful  tnmours,  which  at  the  outset  present  the  appearance  of  a  central 
bone  tumour  and  subsequently  of  a  bone  cyst.  The  affection  occasion- 
ally remains  latent  for  several  years.  Echino- 
coccus cysts  usually  vary  in  size  from  that  of  the 
head  of  a  pin  to  that  of  a  pea,  or  they  form 
large  cysts  (Fig.  3G3,  a)  which  commonly  break 
through  the  cortex  after  they  have  existed  a 
long  time,  and  invade  the  surrounding  soft 
parts,  muscles,  vessels,  and  nerves,  or  neighbour- 
ing joint  (see  below).  As  Bergmann  has  re- 
marked, there  is  sometimes  a  formation  of  ab- 
scesses in  the  tissues  around  the  bone,  which 
after  being  incised  show  no  tendency  to  heal, 
and  may  lead  one  to  suppose  that  there  is  a  ne- 
crosis present.  The  pus  at  times  is  remarkably 
rich  in  cholesterin  crystals,  a  fact  which  is  of 
importance  for  the  diagnosis.  The  atrophy  of 
bone  is  not  infrequently  very  considerable  (Fig. 
364).  It  is  worth  noting  that,  as  Gangolphe 
says,  the  multilocular  form  of  echinococcus  of 
bone  is  by  far  the  most  common  ;  it  was  found 
thirty-two  times  in  thirty-seven  cases,  and  only 
in  five  instances  was  encysted  echinococcus  pres- 
ent (which  is  much  the  more  common  form  in 
the  soft  parts,  especially  in  the  liver).  Of  fifty- 
two  cases,  twenty-six  were  of  the  hollow  bones 
(eleven  humerus,  eight  tibia,  six  femur,  one 
phalanx)  and  eighteen  of  the  flat  bones  (eleven 
pelvis,  four  each  involving  the  skull,  scapula,  and  sternum,  and  the  ribs 
once). 

The  diag7iosis  ca,n  only  be  made  with  certainty  when  the  soft,  fluc- 
tuating tumours  have  broken  through  the  bone,  or  when  a  portion  of 
their  contents  can  be  withdrawn  by  an  exploratory  puncture.  In  the 
case  of  the  long  hollow  bones  the  nature  of  the  disease  is  occasionally 
revealed  by  the  occurrence  of  a  spontaneous  fracture. 

The  jprognosis  is  governed  by  the  location  of  the  disease,  echi- 
nococcus of  the  bones  of  the  skull  and  of  the  vertebrae  and  pelvis 
being  the  most  unfavourable,  while  the  echinococcus  of  the  extrem- 
ities is  less  so.  Gangolphe  states  that  out  of  seven  cases  of  echino- 
coccus of  the  vertebrae,  six  died  of  sepsis  after  the  operation,  while 


Fig.  303. — Echinococcus  of 
the  femur  and  tibia  of  a 
tifty-two-year-old  wom- 
an :  a,  hirjre  ecliinococ- 
cuscyst.  Ainputatiofe- 
mori.s  (Ilalin). 


654 


INJURIES   AND  SURGICAL  DISEASES  OF   BONE. 


of  nineteen  patients  with  echinococcus  of  the  extremities   only  four 
died. 

The  treatment  consists  in  as  complete  a  removal  as  possible  of  the 
cyst  as  well  as  of  the  diseased  bone,  or,  when  this  cannot  be  done,  in  in- 
cision, with  destruc- 
tion of  the  mem- 
brane by  means  of 
the  sharp  spoon, 
Paquelin  thermo- 
cautery, etc.  In 
the  case  of  the  ex- 
tremities, amputa- 
tion or  disarticula- 
tion will  often  be 
necessary.  Of  the 
thirty-six  cases  of 
echinococcus  of 
bone  collected  by 
Eeszey  and  Hahn, 
twenty  were  ope- 
rated upon,  and  of  these  fourteen  were  cured  (two  by  incision,  twelve 
by  amputation).  At  all  events  the  treatment  should  be  as  energetic  as 
possible  so  as  to  prevent  recurrences. 

Echinococcus  in  Joints. — Occasionally,  as  we  have  remarked  before, 
an  echinococcus  of  bone  breaks  through  into  the  neighbouring  joint 
(Fischer  found  ten  such  cases  in  literature)  ;  but  it  is  extremely  rare  for 
the  parasite  to  lodge  primarily  in  the  joints.  Of  the  above-mentioned 
ten  cases,  eight  affected  the  hip  joint,  one  the  knee,  and  one  an  inter- 
phalangeal  joint.  Of  echinococcus  cysts  of  the  pelvic  bones  with  per- 
foration into  the  hip  joint,  only  one  case  has  been  cured  by  operation 
(Bardeleben).  The  treatment  of  this  affection  of  the  joints  demands 
very  energetic  procedures  (resection,  or  even  amputation). 


Fig.  364. — Echinococcus  of  tlie  pelvic  bones  on  the  right  side,  with 
well-marked  resorption  of  the  bones  of  the  pelvis  and  head  of 
the  femur  of  a  twenty-five-year-old  peasant  woman  (Viertel). 


CHAPTER  IV. 

INJURIES    AND    DISEASES    OF   JOINTS. 

Review  of  the  anatomy  of  joints. — The  acute  inflammations  of  joints :  Arthritis  or  syno- 
vitis serosa,  sero-fibrinosa,  and  purulenta. — The  acute  polyarticular  rheumatism. — 
The  secondary  inflammations  of  joints  occurring  in  the  course  of  acute  infectious 
diseases  (metastatic  inflammations  of  joints). — Gonorrhoeal  arthrites. — The  acute 
arthrites  occurring  in  the  course  of  syphilis. — Arthritis  urica  (gout). — Gout  of  lead 
poisoning. — Treatment  of  acute  inflammations  of  joints. — The  chronic  inflamma- 
tions of  joints :  Hydarthros  chronicus. — Chronic  articular  rheumatism. — Chronic 
suppuration  of  joints.  —  The  fungous  (tubercular)  arthrites,  joint  caries.  —  The 
syphilitic  arthrites. — Arthritis  deformans. — Diseases  of  joints  in  bleeders  (haemo- 
philia).— Joint  bodies. — articular  neuralgias,  articular  neuroses  (hysterical  joint  affec- 
tions).— Xeuropathic  inflammations  of  bones  and  joints. — Anchyloses. — Deformi- 
ties of  joints  (contractures).  —  Echinococcus  in  the  joints  (see  page  654).  —  The 
injuries  of  joints:  Subcutaneous  injuries  (contusions,  sprains). — Dislocations  (luxa- 
tions) of  joints. — Wounds  of  joints. — Appendix :  Gunshot  wounds. — Remarks  upon 
\  >0  military  surgery. 

§  112.  Review  of  the  Anatomy  of  the  Joints. — It  is  well  known  that 
the  cavities  of  the  joints  of  the  cartilaginous  skeleton  of  the  fcetus  are 
made  by  dehiscence,  or  softening  and  liquefaction  of  the  formative 
tissue  remaining  between  the  cartilaginous  layers.  They  develop  later 
than  the  ligaments  of  the  capsule,  which,  as  processes  of  the  perichon- 
drium, stretch  across  the  space  lying  between  the  ends  of  the  cartilages. 
The  articulations  between  the  bones  are  commonly  divided  into  two 
classes :  the  synarthroses  and  the  diarthroses.  The  synarthroses  are 
characterised  by  having  a  cartilaginous  or  fibrous  layer  interposed  be- 
tween the  bone  surfaces,  which  is  connected  to  the  periosteum,  the 
latter  extending  from  one  bone  to  the  other.  In  the  diarthroses  the 
continuity  is  completely  interrupted,  and  they  are  provided  with  a 
loose  capsule,  which  is  generally  strengthened  by  accessory  ligaments. 
The  inner  surface  of  the  capsule  of  a  joint,  or  the  so-called  synovial 
membrane,  is  covered  usually  by  a  single  layer  of  endothelium,  which, 
as  my  investigations  show,  very  often  extends  over  the  synovial  fringes 
and  interarticular  ligaments  as  far  as  they  lie  free  in  the  cavity  of  the 
joint,  but  under  normal  conditions  does  not,  as  a  rule,  cover  the  point 
of  origin  of  the  synovial  membrane  at  the  articular  cartilage.     In  the 

(655) 


656 


INJURIES  AND   DISEASES  OP  JOINTS. 


foetus  the  cartilage  is  ordinarily  partially  covered  by  endothelium,  and 
after  birth,  if  a  joint  remains  quiet  for  any  length  of  time,  the  endo- 
thelium will  grow  over  por- 
tions of  the  articular  carti- 
lages and  other  parts  of  the 
joint  which  present  free  sur- 
faces. On  the  inside  of  the 
synovial  membrane  there 
are  found  thread-like  out- 
growths, the  synovial  villi 
(Figs.  365,  366),  which  can 
be  seen  especially  well  as 
floating  structures  when  a 
joint  like  the  knee  is  opened 
under  water.  Some  of  the 
villi  contain  vessels  (Fig. 
366),  others  do  not  ;  and 
some  of  them  are  single 
filaments,  while  others  are 
branched  and  are  pro\'ided  with  daughter  villi.  According  to  the  na- 
ture of  the  tissue,  cartilage  villi,  fibrous  villi,  fat  villi  and  mucous  villi 
can  be  distinguished,  while  between  these  individual  kinds  there  are 


Fig.  365.- 


-Synovial  villi  (knee-joint).   Glyeerin-osmic- 
acid.     X  30. 


Fig.  366.— Vascular  synovial  villi.    Five  per  cent,  bichromate  of  potassium.    Knee-joint  of 

man.     x  30. 


§112.] 


REVIEW   OP  THE  ANATOMY   OP  THE  JOINTS. 


657 


numerous  transition  forms.     Cartilage  cells  are  very  often  found  in  the 
librous  villi. 


Fio.  367. — Lyiiiphiitics  of  the  synovial  nienibraiu-  (kiife-joiiit  of  an  ox). 


The  joint  capsules  are,  as  Fig.  307  shows,  very 
lymph  vessels — a  niatter  of  great  practical  import 
that  there  are  open  communications — stomata, 
as  they  are  called — between  the  lymph  channels 
and  the  joint  cavity  on  the  inner  surface  of  the 
articular  capsule,  as  there  are  in  other  sei'ous 
membranes ;  but  as  yet  I  believe  no  one  has 
been  able  to  demonstrate  them. 

The  hyaline  cartilage  is  only  apparently  ho- 
mogeneous. As  I  was  the  first  to  show  (Archiv 
fiir  Anat.  und  Phys.,  1877),  it  can  be  demon- 
strated by  means  of  trypsin,  or  the  prolonged 
action  of  permanganate  of  potassium,  that  hya- 
line cartilage  is  really  made  up  of  fibres  which 
are  bound  together  by  a  cement  substance. 
The  latter  is  dissolved  by  the  above-mentioned 
materials,  especially  by  the  action  of  trypsin  at 
a  temperature  of  38°  to  40°  C.  (101-4°  to  104° 
F.)  in  the  incubating  oven,  and  the  fibres  are 
then  made  evident  (Figs.  308,  309,  370).  They 
may  have  a  lamellar  arra!igement,  as  in  Fig.  309, 


richly  supplied  with 
ance.     It  is  supposed 


r 


T 


¥ni.  8<kS. — Hyaline  cartilage 
tivnted  in  an  incubator 
with  tn'psin.  Network 
lu-i'unijement  of  the 
fibres.      X  150. 


reticulated  structure  (Figs. 
42 


or  form  a  network,  a 
368,  370).      Through  our  knowledge  that 


g58  INJURIES   AND   DISEASES  OF  JOINTS. 

even  li valine  cartilage  is  constructed  of  fibres,  we  can  more  readily  under- 
stand the  various  changes  which  occur,  for  example,  in  the  calcification 


>•<> 
^ 


-it 


Fig.  369. — Hyaline  cartilatre  treateu  in  au  incu-        Fn^.  ■,',•'. —  ii\;u;iu-    mi^nudf--    iiL-uLtu    lU    a 
bator  with  trypsin.     Arrangement  of  the  hatching  oven  with  trypsin.     Network 

fibres  in  the  form  of  lamellise'.     x  -240.  ■  arrangement  of  the  fibres,      x  240. 

of  the  callus  or  in  the  repair  of  wounds  of  cartilage,  also  the  fibrillation 
of  hyaline  cartilage  which  takes  place  in  chronic  joint  disease,  etc.  AVe 
have  Budge  to  thank  for  his  beautiful  investigations  upon  the  circula- 
tory channels  in  cartilage. 

The  views  of  authorities  vary  as  to  the  origin  of  the  synovia,  but 
my  own  investigations  have  led  me  to  believe  that  it  is  mainly  formed 
bv  the  mucous  and  fat  villi,  partly  by  secretion  and  partly  by  a  break- 
ing up  of  their  cellular  elements.  However,  this  is  not  the  place  to 
discuss  any  more  fully  the  anatomy  and  physiology  of  joints,  and  I 
must  refer  the  reader  to  the  text-books  on  these  subjects ;  but  I  have 
thought  it  wise  to  l)riefly  touch  upon  some  of  the  questions  which  are 
particularly  important  as  regards  the  subject  of  diseases  of  joints.  The 
mucous  bursa:'  are  described  in  ,:::  09. 

^  113.  The  Acute  Inflammations  of  Joints. — We  distinguish,  accord- 
ing to  the  nature  of  the  exudate  in  the  acute  inflammations  of  joints, 
two  general  clas.-es :  the  serous  and  the  siijjjjirrative  arthritis. 

1.  The  arthritis  or  synovitis  serosa  {hydro])s  articidorum  aciitus 
or  hydarthros  acutus)  is  usually  characterised  by  the  presence  of  a 
cloudy,  serous  liquid  containing  a  greater  or  less  number  of  fine  flakes 
of  fibrin.  If  there  is  a  considerable  quantity  of  the  latter  present  the 
arthritis  is  also  called  sero-fibrinosa.  The  other  pathological  changes 
which  occur  in  a  serous  synovitis  consist  in^a  varying  amount  of  hyper- 
temia  and '  swelling,  and  upon  microscopical  examination  there  are 
usually  found' here  and  there  small  focus-like  collections  of  leucocytes 
or  extravasations  of  blood. 


§113.]  THE   ACUTE   INFLAMMATIONS  OF  JOINTS,  659 

The  clinical  course  of  a  serous  syiio%'itis  is  briefly  as  follows:  If 
we  suppose,  for  example,  that  the  knee  joint  is  the  one  affected,  it  is 
usually  swollen  and  feels  hot,  is  tender  to  the  touch,  and  on  palpation 
tiuctiiation  is  plainly  made  out,  and  the  patella  is  lifted  from  its  normal 
position — it  "floats."  Active  and  passive  movements  of  the  joint  are 
possible,  but  cause  pain.  There  is  either  no  fever  at  all  or  only  a  very 
sHght  amount  of  it.  The  further  course  of  the  disease  is  in  the  main 
dependent  upon  the  cause,  but  it  is  ordinarily  favourable,  and  if  proper 
treatment  is  adopted  recovery  will  very  speedily  ensue.  Occasionally 
an  acute  serous  synovitis  will  change  into  the  suppurative  form  or  into 
a  chronic  hydarthros.  Xot  infrequently  after  recovery  from  the  acute 
hydarthros  there  is  a  pronounced  tendency  to  i-elapses. 

2.  The  arthritis  or  synovitis  acuta  puridenta  {emjyyema  of  the 
joint)  is  characterised  anatomically  by  the  formation  of  a  purulent  or 
flbrino-purnlent  exudation.  It  either  follows  a  serous  or  sero-flbrinous 
inflammation  or  begins  as  such.  In  addition  to  the  pure  or  flocculent 
pus  which  is  found  in  the  joint,  there  is  also  usually  present  a  marked 
swelling  and  hyperaemia  of  the  synovial  membrane  and  ligaments  uj)on 
which  a  fibrino-purulent  material  is  deposited,  sometimes  containing 
foci  of  pus.  Furthermore,  the  articular  cartilages  become  dull  in  ap- 
pearance, and  there  is  an  even  extension  of  the  synovial  membrane  over 
their  edges  in  the  form  of  vascular,  newly  developed,  delicate  connect- 
ive tissue.  The  milder  grades  of  suppurative  arthritis,  without  deep 
destruction  of  the  synovial  membrane,  we  shall  designate  as  catarrhal 
suppuration  of  a  joint.  In  the  cases  of  longer  duration,  or  in  the  more 
severe  forms  of  suppuration,  a  suppurative  panarthritis  develops — i.  e., 
all  portions  of  the  joint  are  attacked  by  the  suppuration,  the  cartilage 
undergoes  librillation  and  here  and  there  becomes  necrotic.  The  sup- 
puration may  extend  to  the  bones  and  the  medulla,  and,  after  breaking 
through  the  capsule  of  the  joint,  give  rise  to  periarticular  abscesses,  etc. 
In  the  worst  forms  of  acute  suppurative  arthritis  pjitrefactive  changes 
take  place,  sometimes  accompanied  by  a  marked  evolution  of  gas.  Sup- 
purative inflammation  of  a  joint  may  terminate  in  a  restitutio  ad  in- 
tegrumtm  recovery  with  partial  or  total  stiffness  of  the  joint  (anchylo- 
sis), or"in  death. 

The  clinical  course  of  an  acute  suppurative  inflammation  of  a 
joint  like  the  knee,  is  charactei-ised  by  ' severe  pain,  by^high  fever, 
which  often  begins  suddenly  with  a  chill, 'by  great  swelling,  and  bv 
pronounced  disturbance  of  function.  The  knee  is  usually  slightly 
flexed,  and  the  least  attempt  at  passive  motion  causes  the  most  intense 
pain.  The  skin  generally  feels  very  hot,  and  is  reddened.  At  the 
outset  fluctuation  is  ordinarily  not  present,  but  becomes  capable  of 


6g0  INJURIES  AND   DISEASES  OF  JOINTS. 

detection  as  the  amount  of  pus  increases.  'A  characteristic  feature  of 
suppuration  of  a  joint  is  the  (edematous  swelling  of  the  parts  surround- 
ing it  or  of  the  entire  extremity.  The  subsequent  course  of  the  dis- 
ease depends  upon  the  nature  of  the  infection,  and  especially  upon 
whether  the  suppurative  arthritis  receives  early  antiseptic  treatment. 
If  the  joint  is  opened  and  drained  antiseptically  at  an  early  stage, 
recovery  with  a  movable  joint  may  still  be  obtained;  and  even  in 
neglected  cases  a  restitutio  ad  integrum  is  possible  with  the  help  of 
antiseptics.  In  other  instances  the  acute  suppuration  becomes  chronic. 
Yery  often  recovery  takes  place  with  more  or  less  stiffness,  or  with 
partial  or  complete  obliteration  of  the  joint.  When  the  joint  is  ol)- 
literated  the  granulation  tissue  which  is  present  changes  into  cica- 
tricial tissue — i.  e.,  a  cicatricial  connective-tissue  anchylosis  develops, 
though  sometimes  the  stiffness  is  due  to  bony  nnion  of  the  articular 
ends  of  the  bones  (anchylosis  ossica  i  see  §  118,  Anchylosis).  The 
worst  cases  terminate  in  death  from  pytemia  or  septica?mia,  the  latter 
coming  on  with  great  rapidity  in  the  case  of  putrefaction  of  a  joint, 
unless  operative  measures  are  very  speedily  and  energetically  adopted. 

Suppuration  of  joints  in  arthropathies  is  described  in  §  117,  and 
the  spontaneous  dislocations  which  occur  in  acute  inflammations  of 
joints  in  §  122  (Luxations). 

The  contractures  which  take  place  in  the  course  of  acute  joint  dis- 
eases are  mainly  reflex  in  their  nature  (see  pages  51:0  and  554  ). 

The  Primary  Acute  Suppurative  Synovitis  of  SmaU  Children. — Ki-ause 
has  recently  descriljed  a  primary  acute  suppurative  synovitis  of  small 
children  on  the  basis  of  observations  made  in  Yolkmann's  clinic.  The 
affection  occurs  not  infrequently  in  the  form  of  catarrhal  suppurative 
arthritis  in  children  from  one  to  four  years  of  age,  is  always, non-articu- 
lar, and  attacks  most  commonly  the  shoulder,  ankle,  elj)0w,  and  hip 
joints.  The  course  is  very  acute,  and  is  accompanied  by  the  symp- 
tonis  of  a  phlegmon  ;  but  after  freely  opening  the  joint  recovery  usu- 
ally takes  place  rapidly  without  disturbance  of  function.  Satisfactory 
results  are  often  obtained  even  in  the  cases  where  the  pus  has  spon- 
taneously ruptured  externally,  and  in  neglected  cases.  Not  infre- 
quently spontaneous  luxations  occur.  Krause  found  the  streptococcus 
pyogenes  in  the  pus.  Sometimes  suppurative  inflammations  of  joints 
are  observed  during  early  childhood  in  conjunction  with  injuries  or 
the  acute  exanthemata ;  they  are  generally  caused  by  the  staphylo- 
coccus pyogenes  aureus  or  albus,  and  have  a  pronounced  pyaemic 
character. 

■  ,  Synovitis  Crouposa. — Many  authorities,  including  Bonnet,  have  recog- 
nised, in  addition  to  the  serous  and  suppurative  synovitis,  a  croupous 


§113.j  THE  ACUTE  INFLAMMATIONS  OF  JOINTS.  QCjl 

synovitis  which  is  analogous  to  the  croupous  inflammation  of  mucous 
memhranos.  In  the  croupous  synovitis  there  are  found  in  tlie  cavity  of 
tlie  juint  hirge  amounts  of  coagulated  fibrin ;  the  affected  joints  are 
very  painful,  but  only  slightly  swollen,  and  fluctuation  is  absent.  The 
course  of  this  more  or  less  dry  arthritis  is  unfavourable,  inasmuch  as 
the  joint  becomes  obliterated  in  the  majority  of  instances,  and  firm 
aj^chylosis  results.  As  a  matter  of  fact,  there  are  inflannnations  of 
joints  which  run  a  very  dry  course ;  but  Volkmann  considers  it  ques- 
tionable whether  in  these  cases  there  is  really  a  croupous  inflammation 
of  the  joint. 

Etiology  of  Acute  Inflammations  of  Joints. — The  causes  of  acute  pri- 
mary inflammations  of  joints  are  in  the  main  traumatic,  and  are  chiefly 
to  be  ascribed  to  infection  of  some  injury  by  micro-organisms.  Every 
suppurative  arthritis  is  due  to  the  presence  of  bacteria.  In  the  case 
of  a  serous  synovitis,  however,  taking  cold  cannot  be  left  out  of  ac- 
count as  a  primary  or  exciting  cause.  Primary  acute  inflammations 
of_joints  very  often  originate  secondarily — i.  e.,  they  are  either  the 
result  of  disease  of  the  adjoining  tissues,  such  as  the  medulla,  perios- 
teum, etc.j'or  tliey  are  the  local  expression  of  a  general  systemic  in- 
fection— in  other  words,  they  are  metastatic  inflammations  which  gen- 
erally develop  simultaneously  in  several  joints.  In  the  latter  category 
belong,  for  example,  the  inflammations  of  joints  occurring  in  the  course 
of  p_\-8emia,  typhoid  fever,  the  acute  exanthemata,  and  of  pneumonia  in 
consequence  of  infection  by  Frankel's  pneumococcus,  also  polyarticu- 
lar rheumatism,  arthritis  urica  (gout),  gonorrhoeal  rheumatism,  the  in- 
flammations-of  joints  arising  in  the  course  of  syiDhilis,  chronic  lead  poi- 
soning, etc.  AYe  must  refer  the  reader  to  the  text-books  on  internal 
medicine  for  the  description  of  acute  polyarticular  rheumatism.  It.  will 
suffice  to  sav  here  that  the  entire  course  of  this  disease  suffcrests  an  in- 
fection  by  micro-organisms  with  localisation  in  the  joints  and  other  se- 
rous cavities  (the  endocardium,  for  example).  The  inflammation  of  the 
joints  is  generally  serous,  but  it  may  occasionally  be  suppurative  in  its 
nature.  A.  Monti  found  the  diplococcus  pneumoniae  of  Frankel  and 
Weichselbaum  in  the  pus  of  acute  articular  rheumatism.  At  all  events 
there  are  many  different  kinds  of  micro-organisms  concerned  in  the  so- 
called  acute  polyarticular  rheumatism. 

The  Secondary  Inflammations  of  Joints  which  Occur  in  the  Course  of 
Acute  Infectious  Diseases  (Pyaemia,  Acute  Exanthemata,  etc. i. — The  in- 
flammations of  joints  which  occur  in  the  course  of  acute  infectious  dis- 
eases (p3:8emia,  erysipelas,  puerperal  fever,  measles,  scarlatina,  small-pox, 
typhoid  fever,  diphtheria,  pneumonia,  mumps,  glanders,  dvsenterv,  etc.) 
are  mostly  of  the  suppurative  variety,  and  the  bacterial  forms  which  are 


662  INJURIES  AND   DISEASES  OF  JOINTS. 

characteristic  of  the  primary  disease  are  usually  found  in  the  exudate 
contained  in  the  joint.  In  the  case  of  pneumonia  the  suppurative  ar- 
thritis following  infection  by  Frankel's  pneumococcus  may  develop  be^ 
fore  or  after  the  pneumonia  itself.  The  pysemic  inHammations  of  joints 
run  the  course  of  an  acute  suppurative  catarrh  or  of  an  acute  jnaemic 
gangrenous  arthi-itis,  and  the  disease  is  almost  always  multiple.  If  the 
patient  recovers  from  the  pvifimia  the  inHammation  of  the  joints  will 
ordinarily  subside  with  great  rapidity,  and  not  infrequently  the  joints 
will  regain  perfect  motion  where  one  would  expect  stiffness.  Other 
cases  run  a  very  chronic  course,  like  cold  abscesses. 

The  inflammations  of  joints  which  occur  in  the  course  of  the  acute  ex- 
anthemata (scarlatina,  measles,  small-pox,  typhoid  fever,  diphtheria,  dys- 
entery, etc.)  present  the  picture  either  of  acute  polyarticular  rheuma- 
tism or  of  suppurative  pysemic  arthritis.  During  convalescence  from 
the  acute  infectious  diseases,  however,  we  meet  with  pronounced,  se- 
rous, monarticular  exudations  into  the  joints  which  only  cause  a  slight 
amount  of  pain  ;  this  is  particularly  apt  to  happen  in  typhoid  fever. 
O.  Witzel  has  recently  called  attention  to  the  frequent  occurrence  of 
inflammations  of  bones  and  joints  during  acute  infectious  diseases.* 

Suppuration  in  Neuropathic  Bone  and  Joint  Disease. — Suppuration  in 
neuropathic  bone  and  joint  disease  is  discussed  in  §  117.  The  analgesia 
which  is  the  result  of  disease  of  the  spinal  cord  (tabes,  syringomyelia, 
etc.)  and  peripheral  nerves  is  an  important  etiological  factor  in  the  pro- 
duction of  this  kind  of  suppurative  arthritis,  for  the  reason  that  the  pa- 
tients, in  consequence  of  the  absence  of  their  sense  of  pain,  neglect  inju- 
ries which  they  I'eceive,  and  this  allows  suppurative  infection  to  take 
place. 

Gonorrhoeal  Arthritis. — Great  interest  also  attaches  to  the  gonor- 
rhoeal  inflammations  of  joints — gonorrhoeal  gout  or  rheumatism,  as  it  is 
called.  This  form  of  arthritis  is  rendered  thoroughly  intelligible  to  us 
since  we  know  that  the  specific  catarrh  of  the  urethra  is  excited  b}^  the 
gonococcus  first  described  by  Xeisser.  Petrone,  Bornemann  and  others 
maintain  that,  as  a  result  of  the  sj'stemic  infection  which  may  occur  from 
a  gonorrhcjea,  not  only  the  joints  may  become  diseased,  but  also  the  ten- 
dons and  tendon  sheaths,  the  mucous  bursae,  the  nerves,  the  eyes,  the 
endocardium  and  pericardium,  etc.  This  gonorrhoeal  inflammation 
attacks  by  preference  the  knee  joint,  though  the  affection  often  occurs 
in  a  multiple  form  involving  several  joints,  and  as  a  rule  is  serous 
or  sero-fibrinous,  very  rarely  suppurative,  in  its  nature.  Quite  often 
there  is  a  very  considerable  exudation  into  the  joint.     In  three  hundred 

*  Bonn,  Max  Cohen  &  Son,  1890,  p.  146. 


gll3.J 


THE   ACUTE   INFLAMMATIOXS  OF  JOINTS. 


603 


and  eight  cases  Nolan  states  that  the  knee  was  alfected  eighty-six  times, 
the  ankle  lifty-two,  the  shoulder  twenty-nine,  the  wrist  twenty-six,  the 
hip  fifteen,  the  fingers  and  toes  seventeen,  etc.  Out  of  one  hundred 
and  eighteen  cases,  only  twenty-three  were  monarticular,  and  in  fifteen 
cases  many  joints  were  involved.*  The  course  of  gonorrhceal  rheuma- 
tism in  the  majority  of  instances  is  favourable,  and  after  the  joint  has 
been  punctured  once  or  twice  the  effusion  disappears  entirely,  but  re- 
currences of  the  affection  are  rather  common.  There  are  also  cases 
which  run  a  very  chronic  course,  like  tumor  all)us  or  arthritis  deform- 
ans, and  occasionally  we  encounter  cases  which  are  very  malignant  and 
rapidly  pass  on  to  suppuration.  In  these,  as  a  rule,  there  is  a  mixed 
infection,  and  the  cocci  of  suppuration  will  generally  be  found  in  the 
pus.  But  it  is  sometimes  impossible,  as  Guyon,  Janet  and  otliers  have 
remarked,  to  demonstrate  the  presence  of  gonococci  (see  Special  Sur- 
gery) even  in  a  typical  gonorrhneal  rheumatism  which  does  not  suppu- 
rate. Bornemann  maintains  that  gonorrhceal  rheumatism  should  be 
looked  upon  as  an  ordinary  infectious-wound  disease  due  to  an  invasion 
of  staphylococci  and  streptococci.  The  typical  form  of  the  disease  gen- 
erally makes  its  appearance  during  the  first  month  which  follows  the 
gonorrhoea  ;  according  to  Xolan,  it  developed  sixty-four  times  within 
this  period,  eleven  times  in  the  course  of  the  second  month  after  the 
urethritis  broke  out,  and  twelve  times  after  a  still  longer  interval. 

The  Acute  Inflammations  of  Joints  which  occur  in  the  Course  of  Syphi- 
lis.— In  the  course  of  syphilis  there  are  likewise  observed  monarticular 
and  polyarticular  inflammations  of  joints  which  are  like  a  monarticular 
hydarthros  of  the  knee,  or,  when  polyarticular,  like  acute  rheumatism. 
The  chronic  syphilitic  inflammations  of  joints  are  discussed  in  §  11-1. 

Gout  (Arthntis  Urica). — Gout  is  an  expression  of  the  uric-acid  dys- 
crasia.  The  blood  contains  an  excess  of  the  salts  of  uric  acid,  which 
are  deposited  especially  in 
the  articular  cartilage  (Fig. 
371),  the  capsule,  the  liga- 
ments, and  in  the  parts 
surrounding  the  joints. 
Erbstein,  to  whose  pains- 
taking study  of  gout  we 
are  greatly  indebted,  has 
produced  the  disease  ex- 
perimentally in  cocks  by 
tying  off  the  ureters  and 

destroying  the  secreting  parenchymatous  portion  of  the  kidneys.  This 
very  painful  inflammation  occurs  in  the^orm  of  paroxysms,  and  most 


@ 

i  i 

5) 

© 

II 

1  1 

t 

\ 

ll 

a\1  IJ^awmM 

1 

11 

^i^l^ll^ 

Fig.  3V1. — Deposition  of  needle-shaped  crystals  of  urate 
of  sodium  in  the  articular  cartilage  in  a  case  of  gout. 
X  2.30. 


QQ4:  INJURIES  AND   DISEASES   OP  JOINTS. 

commonly  attacks  the  joints  of  the  toes  {podagrd)^  less  often  those  of 
the  lingers  or  wrists  {chiragra),  for  the  reason  that  disturbances  of  cir- 
culation more  readily  take  place  in  the  terminal  parts  of  the  body. 
Arthritis  nrica  is  mainly  a  disease  of  the  higher  classes,  and  is  more 
common  in  England  than  on  the  Continent,  making  its  appearance  at 
the  earliest  about  the  thirtieth  to  tlie  thirty-hfth  year  of  life,  Gont 
begins  with  a  serous  effusion  into  the  affected  joint,  which  is  very  apt 
to  be  the  one  between  the  metatarsus  and  iirst  phalanx  of  the  great  toe. 
Tlien  follow^s  the  deposition  in  and  around  the  joint  of  crystals  consist- 
ing of  urate  of  sodium  and  compounds  of  uric  acid  with  calcium,  mag- 
nesium, ammonia,  and  hippuric  acid.  The  skin  is  very  much  reddened, 
and  is  exceedingly  tender  upon  tlie  slightest  pressure.  Usually  a  com- 
plete restitutio  ad  integrum  ensues,  but  inasmuch  as  the  attacks  are 
frequently  repeated,  deforming  inflannnations  of  the  joints  may  eventu- 
ally develop,  which  consist  in  a  fibrillation  and  abrasion  of  the  cartilage, 
thickening  of  the  synovial  membrane,  periarticular  tissues,  etc.  There 
is  also  a  formation  of  circumscribed  nodules,  gout  nodes  (tophi)  as  they 
are  called,  containing  chalky  deposits.  Furthermore,  patients  with  gout 
suffer  from  progressive  degenerative  changes  in  the  internal  organs, 
especially  in  the  kidneys  and  walls  of  the  vessels  (atheroma  of  the  ves- 
sels). The  post-mortem  examination  of  individuals  who  have  had  this 
disease  reveals  with  remarkable  frequency  pulmonary  emphysema  and 
chronic  interstitial  nephritis ;  also  calcification  and  degeneration  of  the 
valves  of  the  heart,  particularly  those  of  the  aorta,  apoplexies  of  the 
brain  in  consequence  of  atheroma  of  the  walls  of  the  vessels,  etc. 

Acute  inflammations  of  joints  occurring  in  attacks  and  presenting  a 
clinical  picture  which  is  like  arthritis  urica,  are  also  sometimes  observed 
in  the  course  of  chronic  lead  poisoning. 

The  Diagnosis  of  Acute  Inflammation  of  a  Joint. — The  diagnosis  of 
acute  arthritis  can  in  the  majority  of  instances  be  made  with  ease  from 
the  description  given  above.  In  making  the  examination  the  diseased 
side  should  always  be  compared  with  the  healthy  one.  Any  exudate 
which  may  be  contained  in  the  joint  adapts  itself  to  the  form  of  the 
latter.  A  test  puncture  with  a  hypodermic  needle — which,  of  course, 
must  l)e  carried  out  with  every  antiseptic  precaution — will  give  accurate 
information  as  to  the  nature  of  the  exudate  in  the  joint,  whether  it  is 
serous  or  purulent.  For  the  rest,  I  must  refer  the  reader  to  what  we 
have  said  as  regards  diagnosis  in  the  chapter  on  Inflammation  (see 
pages  251-252).   / 

The  Treatment  of  Acute  Inflammation  of  a  Joint. — The  treatment  of 
acute  serous  synovitis,  acute  hydarthros,  consists,  at  the  outset,  in  main- 
taining the  part  in  a  quiet  (elevated)  position,  possibly  with  the  aid  of 


§113.J  TIIK  ACUTE   INFLAMMATIONS  OF  JOINTS.  665 

splints,  and  in  the  ajijilication  of  ice.  As  soon  as  the  inflammatory 
manifestations,  especially  the  pain,  have  subsided,  the  serous  exudate 
which  may  be  present  should  be  caused  to  disappear'by  compression 
with  elastic  bandages — the  ordinary  rubber  bandage,  for  example — aTid 
by  massage  practised  once  or  twice  daily,  and  the  patient  then  per- 
mitted to  walk  about.  The  treatment  by  rest  should  not  be  continued 
too  long  a  time  in  acute  hydarthros,  for  the  reason  that  the  affection 
may  then  easily  take  on  a  chronic  character. 

If  the  effusion  is  under  great  tension,  if  absorption  is  delayed,  or  if 
the  hydrops  has  become  chronic,  the  joint  should  be  punctured  aseptic- 
ally.  The  area  of  skin  over  the  joint  is  carefully  scrubbed  with  soap, 
shaved,  and  washed  with  a  five-per-cent.  solution  of  carbolic  acid  or  a 
one-tenth-per  cent,  solution  of  bichloride  of  mercury.  The  eff'usion  in 
the  joint  is  then  compressed  with  the  left  hand,  and  the  joint  opened 
with  a  trocar  which  has  been  sterilised  by  boiling  it  for  five  to  ten  min- 
utes in  a  one-per-cent.  solution  of  soda  (see  page  69,  Fig.  50),  or  by 
heating  it  red-hot,  or  with  a  large  hollow  needle  of  an  aspirator  simi- 
larly sterilised,  or  simply  by  puncture  or  incision  with  the  knife.  After 
the  exudate  has  been  evacuated  the  joint  can  be  washed  out  with  a 
three-per-cent.  solution  of  carbolic  or  a  one-tenth-per-cent.  solution  of 
bichloride.  In  pure  serous  effusions  I  usually  avoid  this  washing  out, 
but  perform  the  operation  if  the  effusion  is  sero-fibrinous  and  contains 
a  slight  amount  of  pns.  After  puncturing  it  the  joint  is  immobilised 
l)y  splints  and  an  antiseptic  dressing  wdiich  exerts  pressure.  The  aseptic 
puncture  of  a  joint  with  the  trocar,  aspirator,  or  knife  is  entirely  devoid 
of  danger  if  the  rules  of  asepsis  are  carefully  observed  and  if  pains  are 
taken  to  prevent  the  entrance  of  air  into  the  joint — in  short,  if  the 
operation  is  performed  with  the  utmost  possible  caution.  Schede,  in 
particular,  has  obtained  satisfactory  results  by  antiseptic  puncture  and 
washing  out  the  joints  in  hydrops,  hsemarthros,  etc. 

Treatment  of  Acute  Suppurative  Arthritis. — If  there  is  pronounced 
suppuration  in  a  joint,  aseptic  puncture  followed  by  irrigation  of  the 
joint  with  a  three-per-cent.  carbolic  or  one-tenth-per-cent.  bichloride 
solution  may  be  practised  in  those  cases  in  which  the  suppuration  is 
still  in  its  inception;  but  if  the  suppuration  is  well  marked  and  there  is 
high  fever,  the  joint  must  be  immediately  opened  by  a  free  incision  and 
drained  (§  31),  and,  if  necessary,  resection  of  the  joint  (§  40)  must  be 
pei-formed.  If  the  test  puncture  (with  the  hypodermic  needle)  reveals 
acute  suppuration,  the  expectant  treatment  by  elevation,  ice,  and  immo- 
bilising dressings,  which  used  to  be  employed,  should  be  discarded,  and 
operative  treatment  by  incision  and  drainage  or  resection  should  be 
straightway  adopted  in  its  place.      U hi  pus  ihi  evacua!     After  the 


C^QQ  INJURIES  AND   DISEASES   OF  JOINTS. 

operation  the  joint  is  placed  in  a  suitable  position  and  carefully  immo- 
bilised by  splints  and  antiseptic  dressings.  When  the  arthritis  is  sup- 
purative a  careful  examination  should  always  be  made  to  determine 
whether  periarticular  collections  of  pus  are  present.  In  cases  where 
the  suppuration  is  severe,  permanent  antiseptic  irrigation  should  be 
used  (page  178).  In  the  vi'orst  forms  of  suppurative  arthritis  with 
putrefactive  changes  it  is  often  necessary  to  perform  an  amputation  in 
order  to  save  the  patient's  life.  If  after  suppuration  of  a  joint  recov- 
ery takes  place,  with  motion  in  the  latter,  we  improve  the  motility  as 
much  as  possible,  after  the  inflammation  has  completely  subsided,  by 
passive  motion,  massage,  and  electricity.  If  recovery  takes  place  with 
anchylosis,  the  joint  must  be  made  to  assume  a  position  which  will  be 
as  useful  as  possible  for  the  patient.  The  ankle  and  the  elbow,  for 
example,  should  be  kept  in  a  right-angled  position,  but  the  other  joints 
must  be  extended. 

The  treatment  of  the  secondary,  metastatic  inflammations  of  joints 
is  precisely  the  same  as  for  those  which  are  primary.  If  many  joints 
are  attacked  by  suppuration,  and  there  is  a  severe  or  hopeless  constitu- 
tional disease,  one  w^ould  probably  relincpiish  all  idea  of  adopting  ener- 
getic operative  measures,  and  simply  provide  an  escape  for  the  pus  by 
incision  and  drainage,  and  alleviate  any  pain  which  the  patient  may 
suffer. 

Treatment  of  Acute  Polyarticular  Rheumatism. — Acute  polyarticulai- 
rheumatism  is  treated  by  immobilisation  of  the  joints  with  splints  of 
wood,  pasteboard  (see  page  223),  or  water-glass ;  by  placing  the  limb 
in  an  elevated  position,  and  by  administering  internally  diaphoretics 
and  diuretics,  particularly  salicylic  acid  or  salicylate  of  sodium  (3-0  to 
6*0  grammes  ji?/'6>  die).  I  ordinarily  give  to  adults  four  to  six  grammes 
of  salicylate  of  sodium  in  wafers  or  a  mucilaginous  mixture  (with  aq. 
dest.  and  mucilag.  gummi  mimos.,  aa  50*0  grammes)  about  every  two 
to  three  hours.  If  0-50  to  1"0  gramme  of  salicylic  acid  are  given  in 
wafers,  or  the  above-described  mixture,  one  should  not  neglect  to  make 
the  patient  drink  a  glass  of  water  after  each  dose,  as  otherwise  the 
stomach  may  easily  become  disordered.  I  must  refer  the  reader  to 
the  text-books  on  internal  medicine  for  the  rest  of  the  treatment  of 
acute  polyarticular  rheumatism,  including  any  cardiac  complications 
which  may  arise. 

Treatment  of  Gout. — The  local  treatment  of  gout  consists  in  allevi- 
ating the  pain  by  placing  the  part  in  a  proper  (elevated)  position  and 
in  enclosing  the  inflamed  joint  in  cotton,  so  as  to  exert  pressure.  The 
joint  in  question  is  painted  over  with  fat  or  vaseline  and  enveloped  with 
dry  cotton,  or  a  hydropathic  dressing  is  applied  around  it.     Lithium, 


4^114.]  TIIK   CHRONIC    INFLAMMATIONS   OF  JOINTS.  6G7 

salicylate  of  sodium,  etc.,  are  given  internallj.  Diaphoretic  remedies 
are  supposed  to  shorten  the  attacks.  The  patient  is  put  upon  a  light 
diet,  and  Moselle  wine  with  seltzer,  or  some  such  beverage,  is  given 
him  to  driidc.  The  morbid  diathesis  is  treated  by  a  moderation  in  the 
patient's  mode  of  living,  especially  as  regai-ds  alcohol,  by  a  meat  diet, 
which  must  not  be  too  excessive,  and  by  the  use  of  Carls1)ad,  Kissin- 
gen,  Marienliad,  Wiesbaden,  Levico,  Vichy,  and  other  saline-spring 
waters ;  the  hot  baths  of  Gastein,  Teplitz,  Wiesbaden,  etc.,  are  also 
worthy  of  recommendation. 

Treatment  of  Gonorrhceal  Rheumatism. — The  milder  cases  of  gonor- 
rhaial  inflammatloiu  of  joints  are  treated  by  rest  in  bed,  by  ice,  by 
immobilising  dressings,  and  by  a  simple  diet.  Internally  we  occasion- 
ally give  four  to  six  grannnes  of  salicylate  of  sodium  jyro  die.  In  the 
case  of  large  effusions  puncture  and  antiseptic  irrigation  of  the  joint, 
as  described  above,  should  not  be  too  long  delayed.  In  the  rare  in- 
stances of  suppuration  of  the  joint  the  rules  given  on  page  665  should 
be  followed.  For  gonorrhceal  rheumatism  Vogt  recommends  the  in- 
jection of  a  bichloride-of-mercury  solution  into  the  joint  (0"1  gramme 
bichloride,  1"0  gramme  sod.  chlor.,  and  aq.  destil.  50'0  cubic  centime- 
tres ;  three  to  five  hypodermic  syringes  to  be  injected  into  the  joint 
each  time  at  intervals  of  three  days).  Konig  praises  injections  of  a 
tive-per-cent.  carbolic-acid  solution.  During  the  acute  inflammatory 
stage  of  the  arthritis  the  treatment  of  the  gonorrha?a  which  is  present 
should  be  deferred,  but  later,  under  all  circumstances,  it  must  be  cured 
as  soon  as  possible  (see  Special  Surgery).  After  the  inflammation  of 
the  joint  has  subsided  it  will  often  be  advantageous  to  wear  an  elastic 
bandage,  and  a  splint  apparatus  may  possibly  be  necessary,  particularly 
in  the  case  of  the  knee,  if  the  latter  has  been  inflamed  for  some  time. 
I  do  not  think  that  massage  should  l)e  used  after  the  subsidence  of  a 
gonorrhceal  arthritis,  for  the  reason  that  recurrences  of  the  affection 
may  thus  be  lighted  up,  the  niicro-organisms  being  again  introduced 
into  the  circulation  and  carried  off  to  other  portions  of  the  body.  I 
have  seen  very  satisfactory  and  permanent  cures  brought  about  in  pro- 
tracted and  malignant  cases  by  a  residence  in  southern  climates — 
Riviera,  Sicily,  Egypt,  Tunis. 

The  symptomatology  and  treatment  of  the  acute  inflammations  of 
individual  joints  is  described  in  the  Text-Book  on  Special  Surgery.  / 

§  111.  The  Chronic  Inflammations  of  Joints. — The  chronic  inflamma- 
tions of  joints  are  divided,  according  to  differences  in  pathology,  into 
two  main  groups,  namely,  the  dry  (arthritis  sicca)  and  the  exudative 
inflammations  of  joints  (arthritis  exudativa,  with  or  without  a  forma- 
tion of  new  tissue  or  of  granulations).     The  subject  of  chronic  arthritis 


668  "   INJURIES   AND   DISEASES  OF  JOINTS. 

is  of  very  great  practical  importance,  and,  among  others,  Billroth, 
Bonnet,  Volkmann,  Oilier,  C.  llueter  and  Konig  have  done  much  to 
advance  our  knowledge  of  it. 

I,  Arthritis,  or  Synovitis  Chronica  Serosa  {Hydarthros,  Chronic 
Hydrops  of  a  Joint,  Ckronie  Dropsy  of  a  Joint). — Il^darthros,  or 
chronic  articular  hydrops,  either  begins  very  gradually  as  sucli,  or  it 
'  follows  an  acute  serous  synovitis. 

The  pathological  changes  which  occur  in  a  synovitis  chronica  serosa 
(hydarthros)  are  essentially  as  follows  :  The  fluid  which  collects  in  the 
joint  is  either  thin  and  watery,  or  it  is  thick,  gelatinous,  or  colloid. 
The  exudate  is  sometimes  remarkably  rich  in  endothelium  (Volkmann's 
endothelial  catarrh).  The  secondary  changes  in  the  cartilage  and  cap- 
sule of  the  joint  are  usually  slight;  but  after  the  process  has  lasted 
a  long  time  the  synovial  meml)rane  becomes  thickened,  the  villi  are 
increased  in  size  and  numbers,  the  joint  cartilage  becomes  thickened 
and  fibrillated,  and  the  synovial  membrane  grows  over  the  free  sur- 
faces of  the  cartilage  (Hueter's  synovitis  hyperplastica  Isevis  or  pannosa). 
The  synovial  membrane  occasionally  projects  through  the  stretched 
external  tibres  of  the  capsule  in  the  form  of  a  synovial  hernia.  After 
the  hydarthros  has  existed  a  long  time  the  ligaments  and  capsules  of 
the  joint  become  stretched,  sometimes  to  such  a  degree  that  the  joint 
loses  its  normal  firmness  and  becomes  flail-like,  and  displacements,  sub- 
luxations, or  complete  luxations  of  the  articular  ends  of  tlie  bones  fol- 
low. If  a  rupture  of  the  capsule  of  the  joint  takes  place  spontaneously, 
or  as  a  result  of  a  traumatism,  a  periarticular  effusion  will  make  its  ap- 
pearance. The  neighbouring  mucous  bursse  which  communicate  with 
the  joint  are  often  similarly  diseased. 

The  causes  of  hydarthros  are  traumatisms  (contusions  and  sprains), 
infection,  such  as  syphilis  or  gonorrhoea,  taking  cold,  and  the  presence 
of  loose  bodies  in  the  joint. 

The  sy7np)to)iis  are  in  the  main  the  same  as  those  of  an  acute  serous 
arthritis,  with  the  single  difference  that  inflammatory  manifestations 
are  usually  absent.  Hydarthros,  or  chronic  serous  synovitis,  most 
commonly  occurs  in  the  knee,  and  in  this  situation  the  effusion  into 
the  joint  can  best  be  demonstrated  by  placing  the  leg  in  the  extended 
position.  Yery  often,  if  the  affected  joint  is  moved,  a  creaking  and 
rubbing  can  be  felt  and  heard,  and  is  mainly  caused  by  a  thickening  of 
the  synovial  membrane,  by  hypertrophy  of  the  villi,  together  with  an 
increase  in  their  number,  and  by  fibrillation  of  the  cartilage,  or  by  the 
formation  of  loose  joint  bodies.  The  tendency  to  the  formation  of 
free  joint  bodies  (see  §  115)  in  hydarthros  occasionally  exists  in  a 
marked  degree.     The  course  of  chronic  serous  synovitis  or  hydarthros 


§114.]  THE   CnROXlC   INFLAMMATIONS  OF  JOINTS.  669 

is  generally  favourable  if  the  disease  receives  proper  treatment,  and 
only  in  rare  instances  do  we  meet  with  the  above-mentioned  deforming 
changes  in  the  synovial  membrane,  the  articular  cartilages,  or  in  the 
entire  articular  a])paratus. 

The  best  treatment  for  chronic  serous  synovitis  consists  in  the  use 
of  massage  (see  page  505)  and  of  compression  of  the  effusion  by  means 
of  rubber  or  elastic  bandages.  It  is  of  the  utmost  importance  that  the 
patient  should  not  protect  his  joint — should  not  keep  it  quiet — but 
rather  should  use  it  industriously.  If  this  does  not  bring  about  a  cure 
and  cause  the  effusion  to  disappear,  the  latter  should  be  i-emoved  in 
the  manner  described  above,  by  aseptic  puncture,  with  or  without  a 
8ul)sequent  washing  out  of  the  joint  with  a  tliree-per-cent.  solution  of 
carbolic  acid  or  with  a  one-tenth-per-cent.  solution  of  bichloride  of 
mercury.  After  the  puncture  the  joint  must  of  course  be  immobilised 
in  a  suitable  (elevated)  position  during  the  next  few  days  by  an  anti- 
septic dressing  applied  so  as  to  exert  pressure.  If  the  reaction  follow- 
ing the  irrigation  is  too  severe,  it  should  be  combated  with  ice.  As  a 
general  thing,  simple  evacuation  of  the  effusion  by  puncture,  without 
antiseptic  irrigation,  will  suffice  in  the  majority  of  cases  of  hydarthros. 
A  few  days  after  removing  the  efl'usion  the  joint  should  be  massaged 
and  vigorously  moved,  and  from  time  to  time  enveloped  in  an  elastic 
bandage.  Any  recurrences  which  may  take  place  can  be  speedilv 
cured  by  massage,  elastic  compression,  and  movement  of  the  joint. 
The  treatment  at  one  time  much  in  vogue,  by  irritation  of  the  skin 
(tinct.  of  iodine)  and  by  the  administration  of  internal  remedies 
(tartar,  stibiat.),  has  very  properly  been  abandoned,  and  kj^eping^the 
joint^uiet  is  actually  injurious.  I  never  make  use  of  the  injection  of 
tincture  of  iodine  into  the  joint — a  procedure  by  no  means  devoid  of 
danger. 

II.  Chronic  Articular  Eheumatisin  ( Rheumatismus  Chronicvs  Ar- 
ticulornm,  PolyartJiritis  Rheuraatica  Chronica). — By  chronic  articular 
rheumatism  we  understand  an  inflammation  of  the  synovial  membrane 
running  an  exceedingly  slow  course,  which  occurs  almost  exclusively 
in  adults,  generally  after  the  thirtieth  to  the  fortieth  year,  and  always 
attacks  several  joints.  There  is  irenerallv  a  crraduallv  increasinor  dis- 
turbance  in  the  function  of  the  joints,  which  ordinarily  in  the  end 
leads  to  complete  stiffness  or  anchylosis  of  the  joint. 

The  anatomical  changes  which  occur  in  chronic  articular  rheu- 
matis!n  consist  essentially  in  a  chronic  inflammatory  formation  of  new 
connective  tissue  in  the  synovial  membrane  and  surrounding  parts 
which  have  a  tendency  to  shrink  and  become  hard  and  dense,  in  a 
flbi'illation  of  the  cartilage,  and  in  a  substitution  for  the  latter  of  vascu- 


670  INJURIES  AND   DISEASES  OF  JOINTS. 

lar  connective  tissue.  The  connective-tissue  metaplasia  of  the  cartilage 
is  brought  about  mainly  by  growth  on  the  part  of  the  synovial  mem- 
brane, though  it  is  very  largely  promoted  by  the  increased  formation 
^  of  medullary  spaces  in  the  deeper  layers  of  cartilage,  and  by  inflamma- 
tory changes  with  a  formation  of  new  vessels  in  the  subchondral 
medulla.  •'  As  the  new  formation  of  connective  tissue  increases,  the 
cavity  of  the  joint  grows  steadily  smaller.  The  stiffness  of  the  joint, 
the  anchylosis,  is  at  the  outset  due  to  connective-tissue  adhesions  which 
niav  eventually  ossify,  the  process  spreading  from  the  spongiosa  until 
the  entire  joint  may  become  tilled  with  bone.  Chronic  articular  rheu- 
matism never  leads  to  suppuration,  and  never  to  true  caries,  the  patho- 
logical changes  presenting  more  of  a  similarity  to  arthritis  deformans, 
except  that  in  the  latter  disease  there  is  more  an  increased  growth  of 
cartilage,  wliile  in  the  former  the  cartilage  is  replaced  by  vascular  con- 
nective tissue.  But  deformities  of  the  joints,  subluxations  and  luxa- 
tions develop  in  chronic  articular  rheumatism  as  they  do  in  arthritis 
deformans. 

Chronic  articular  rheumatism  either  follows  an  acute  rheumatism, 
or  it  begins  insidiously  as  a  chronic  disease  which  lasts  many  years,  and 
is  very  frequently — in  fact,  as  a  rule — incurable.  Gradually  many 
different  joints  become  affected,  and,  in  rare  instances,  all  the  joints  of 
the  body.  The  disease  is  most  common  in  the  lower  walks  of  life, 
and  hence  the  name  arthritis  pauperum.  The  causes  which  are  given 
for  it  are  particularly  taking  cold,  getting  wet  through,' damp  dwell- 
ings, etc.  It  is  observed  almost  exclusively  in  adults ;  and  only  in 
exceptional  instances  are  severe  cases  with  deformities  of  the  joints, 
resembling  arthritis  deformans,  met  with  during  childhood  (Wagner). 
As  in  acute  rheumatism,  it  is  still  uncertain  as  to  how  much  of  a  part 
is  played  by  micro-organisms  in  the  production  of  the  chronic  poly- 
V-'     articular  rheumatism. 

The  sul)jective  symptoms  consist  in  sharp,  severe  pains  felt  now  in 
this  and  now  in  that  joint.  The  movements  of  the  joints,  particularly 
in  the  morning,  after  the  night's  rest,  are  limited  and  cause  pain ;  but 
during  the  day,  after  the  patient  has  used  his  limbs  somewhat,  the 
mobility  of  the  joints  improves.  In  other  instances  th'e  joints  are  so 
painful  that  no  movements  at  all  can  be  performed.  The  joints  are 
usually  somewhat  swollen  ;  and  in  many  cases — i.  e.,  in  the  so-called 
fungous  form  of  articular  rheumatism — the  growth  of  connective  tissue 
is  so  considerable  that  the  joints  present  the  appearance  of  tumor 
albus.  If  the  joints  are  moved,  a  creaking  or  crackling  friction  sound, 
due  to  the  newly  formed  connective  tissue  and  to  the  iibrillation  of 
the  cartilage,  can  very  frequently  be  made  out.     As  a  rule,  subacute 


8114.1  THE  CHRONIC   INFLAMMATIONS  OP  JOINTS.  671 

exacerl)atit>ns  of  tlio  subjectivo  jukI  objoctive  symptoms  take  place  at 
irregular  intervals,  the  joints  hecome  steadily  stilTer,  and  the  muscles 
atroi)hy  more  and  more,  so  that  these  pitiable  individuals  grow  con- 
stantly more  helpless,  and  death  oi'teii  occurs  from  general  marasmus 
or  some  intercurrent  disease.  In  other  cases  the  disease  gets  well  with 
j)artial  or  total  anchylosis  of  the  affected  joints.  I  saw  a  divinity 
student  who  had  complete  anchylosis  of  both  hips,  both  knees,  the 
right  elbow,  and  the  left  wrist ;  and  Percy  found  anchylosis  of  all  the 
joints  of  the  body  in  a  French  officer  who  died  in  his  fiftieth  year. 
The  skeleton  of  this  officer,  who  had  suffered  from  chronic  articular 
rheumatism  contracted  in  his  campaigns,  has  been  preserved  in  the 
ficole  de  Medecine,  and  forms,  to  all  appearances,  a  single  piece  of 
bone. 

The  diagnosis  of  chronic  polyarticular  rheumatism  can,  in  all 
probability,  be  readily  made  from  what  has  been  said  above  ;  but 
the  milder  cases  are  often  difficult  to  differentiate  from  gout  and 
arthritis  deformans.  We  have  also  made  the  prognosis  sufficiently 
clear. 

The  treatment  of  chronic  polyarticular  rheumatism  generally  de- 
mands a  great  deal  of  patience,  and  even  then,  I  am  sorry  to  say,  is 
often  entirely  unsuccessful.  In  cases  which  are  not  of  long  standing, 
massage  and  methodical  exercise  of  the  joints  should  be  tried  in  com- 
bination with  hydrotherapy  (baths,  steaming,  douches,  etc.).  The  joint 
should  not  be  kept  quiet  in  the  early  stages  of  a  chronic  rheumatism. 
If  massage  and  movement  of  the  joint  are  too  painful,  they  must  be 
carried  out  occasionally  under  chloroform  anaesthesia.  I  have  seen 
very  satisfactory  and  permanent  cures  obtained  by  this  treatment  in 
cases  which  had  not  existed  too  long  a  time.  Furthermore',  the  use  of 
hot  springs,  such  as  Gastein,  Teplitz,  Wiesbaden,  Wildbad,  and  Ragatz- 
Pfaffers,  and  a  residence  in  warm  climates,  are  very  valuable.  Volk- 
mann  recommends  the  internal  administration  of  cod-liver  oil  and  iron, 
and  iodide  of  potash  or  vinum  semin.  colchici.  The  use  from  time  to 
time  of  salicylic  acid  or  salicylate  of  sodium  is  exceedingly  serviceable. 
But  often  on  account  of  the  se\^-e  pain  massage  cannot  be  carried  out, 
or  the  joints  may  already  have  undergone  too  extensive  changes.  In 
such  cases,  which  are  generally  of  long  standing,  we  are  often  com- 
pelled to  confine  ourselves  to  oj-thopsedic  treatment,  placing  the  dis- 
eased joints  in  a  good  position,  under  chloroform  anaesthesia,  and 
immobilising  them  by  plaster-of-Paris  splints.  As  a  result  of  the  rest 
given  the  joints  by  the  plaster  of  Paris,  the  pain  ordinarily  becomes 
less,  but  at  the  same  time  the  occurrence  of  anchylosis  is  favoured. 
After  having  kept  the  diseased  joints  quiet  by  splints  for  a  long  time, 


672 


INJURIES  AND   DISEASES  OF  JOINTS. 


it  lias  been  my  experience  that  all  hopes  of  the  possibility  of  oljtaining 
a  cure  with  a  movable  joint  must  generally  be  given  up,  and  a  recovery 
with  anchylosis  be  striven  for.  Sonnenburg  has  recently  obtained  very 
surprising  success  in  chronic  articular  rheumatism  by  laying  the  joint 
widely  open  (arthrotomy)  and  then  washing  it  out  antiseptically  and 
packing  the  cavity  with  iodoform  gauze.  Schiiller  recommends  injec- 
tions of  a  sterilised  two-per-cent.  boro-f-alicylic  solution  or  a  three-  to 
five-per-cent.  iodoform-glycerin  solution  ;  but  in  the  severe  chronic 
cases  he  also  advises  operative  treatment,  such  as  arthrectomy  (see  page 
129).  I  have  not  seen  any  success  from  intra-articular  injections  in 
chronic  rheumatism,  but  I  believe,  with  Sonnenburg  and  Schiiller,  that 
chronic  articular  rheumatism  in  its  later  stages,  especially  if  there  is 
great  pain,  should  receive  operative  treatment  more  frequently  and 
earlier  than  it  ordinarily  does.  Sonnenburg's  method  of  freely  open- 
in<'  the  joint,  washing  it  out  antiseptically  and  packing  it  with  iodoform 
gauze  will  generally  suffice,  though  if  the  disease  is  severe  arthrectomy 
may  be  indicated. 

III.  Chronic  Suppuration  of  Joints. — Every  suppuration  of  a  joint  is 
the  result  of  infection  Ijy  micro-organisms.  The  infection  takes  place 
'in  conjunction  with  a  traumatism,  for  example,  or  by  way  of  the  cir- 
culation, or  in  consequence  of  the  extension  to  the  joint  of  a  suppura- 
tive inflammation  in  the  surrounding  parts  (medulla,  ]ieriosteum,  soft 
parts).  In  chronic  suppuration  of  a  joint  the  synovial  membrane  is 
usually  the  seat  of  an  inflannnatory  infiltration  and  is  covered  with 
fibro-purulent  masses,  the  cartilage  is  cloudy  and  fibrillated,  and  losses 
of  substance  develop  in  it  (cartilage  ulcers) ;  occasionally  large  portions 
of  the  cartilage  necrose  and  separate  from  the  underlying  parts,  or  the 
cartilage  is  completely  destroyed.  The  suppuration  very  often  spreads 
to  the  medulla,  the  periosteum,  and  the  periarticular  tissues.  The  joint 
becomes  more  or  less  altered  according  to  the  severity  and  duration  of 
the  suppuration,  and  in  pronounced  cases  which  have  existed  for  a 
long  time  fibrous  or  bony  anchylosis  usually  develops  when  recovery 
takes  place,  a^we  remarked  before  in  discussing  the  subject  of  acute 
suppurative  arthritis. 

AVe  shall  first  take  up  that  form  of  chronic  suppuration  of  joints 
which  is  due  to  tuberculosis. 

IV.  The  Chronic  Fungous  and  Suppurative  i  Tuberculan  Inflammations 
of  Joints  Tuberculosis  of  Joints — Tumor  Albus— Tubercular  Caries  of 
Joints— Fungus  of  Joints. — All  these  terms  indicate  one  and  the  same 
disease,  viz.,  tuberculosis  of  joints  or  tubercular  arthritis. 

Tubercular  arthritis  is  generally  a  secondary  inflammation — i.  e.,  it 
originates  most  commonly  in  conjunction  with  a  tubercular  focus  in 


^IM.J  THE   CHRONIC   INFLAMMATIONS   OF  JOINTS.  673 

the  medulla  (in  the  epiphyses  of  the  long  bones,  for  example,  or  in  the 
periosteum) ;  less  frequently  the  tuberculosis  is  })rimary  in  the  joint. 
Primary  tuberculosis  of  a  joint  may  begin  in  any  part  of  it,  particu- 
larly in  the  bone  and  synovial  membrane ;  ])ut,  as  far  as  I  know,  no 
case  of  primary  tuberculosis  has  hitherto  been  observed  which  origi- 
nated in  the  ground  substance  of  the  cartilage.  Miiller's  statistics,  ob- 
tained from  Konig's  clinic,  show  that  in  two  hundred  and  thirty -two 
cases  of  tubercular  arthritis  one  hundred  and  fifty-eight  started  in  the 
bones,  forty-six  in  the  synovial  membrane,  and  in  twenty-eight  cases 
the  point  of  origin  was  uncertain.  AVe  remarked  on  page  610  that 
the  anatomical  structure  of  the  medulla  is  especially  favourable  to  a 
deposition  from  the  blood  of  the  tubercle  bacilli,  and  we  likewise  em- 
phasised the  fact  that  tubercular  arthritis  develops  very  often  after  the 
reception  of  some  traumatism.  The  general  subject  of  tuberculosis 
and  of  tuberculosis  of  bone  is  described  in  §  S3  and  §  105,  and  there- 
fore we  shall  confine  ourselves  here  to  the  presentation  of  the  tubercu- 
losis which  is  peculiar  to  joints. 

The  Pathological  Changes  which  Occur  in  Tubercular  Arthritis. — The 
pathological  changes  which  occur  when  a  juiut  is  infected  hy  tubercle 
bacilli,  no  matter  whether  the  infection  is  primary  in  the  joint  or 
secondary  to  similar  disease  in  the  medulla,  periosteum,  or  periarticular 
soft  parts,  are  as  follows :  The  bacilli  enter  by  one  or  more  points  of 
infection,  and  are,  so  to  speak,  planted  in  different  parts  of  the  joint, 
where  they  give  rise  to  the  development  of  tubercles  which  have  the 
structure  that  we  described  on  a  previous  page  (407).  The  synovial 
membrane  undergoes  inflammatory  changes,  and  is  filled  with  charac- 
teristic greyish-white  nodules,  and  as  the  tuberculosis  advances  it  is 
possible  to  distinguish  three  different  forms  of  the  disease,  which,  to  be 
sure,  merge  into  one  another:  (1)  The  pure  miliary  form  ^  without  the 
formation  of  a  spongy,  so-called  fungous  tissue,  (2)  the  fungous  form, 
and  (3)  the  fhrous,  with  the  formation  of  lardaceous  thickenings.  The 
fungous  form  of  tubercular  arthritis  is  tlie  most  common,  and  in  it  the 
synovial  membrane  becomes  changed  into  a  spongy,  red  granulation 
tissue  filled  with  tubercles,  while  during  the  early  stages  the  joint  con- 
tains a  serous  or  sero-fibrinous  exudate  (hydrops  tuberculosus),  and  later 
on  pus  in  which  there  are  generally  small  particles  of  cheesy  matter 
(cold,  tubercular,  suppurative  arthritis).  The  tubercular  granulation 
tissue  in  course  of  time  grows  into  all  parts  of  the  joint,  pushes  its 
way  over  the  cartilage  and  ligaments,  and  penetrates  into  the  bone  and 
medulla,  etc.  ;  in  short,  wherever  the  tubercular  granulation  tissue  de- 
velops the  original  tissue  is  destroyed.     In  the  case  of  tuberculosis  of 

bone  the  portion  of  the  latter  which  is  affected  by  the  disease  either 
43 


674 


INJURIES   AND   DISEASES  OF  JOINTS. 


necroses  in  toto  (Fig.  372),  or  several  isolated  sequestra  are  formed  (Fig. 
373).  lu  the  caput  femoris,  for  example,  very  characteristic  cuneiform 
sequestra  are  frequently  observed  (Fig.  372)  which  are  similar  to  the 


Fig.  372. — Larire  infaret-sliaped  sub- 
chondral tubercular  focus  in  the 
head  of  the  femur,  which  is  in  an 
advanced  stage  of  demarcation  ; 
the  articular  cartilasre  is  lifted  up 
like  a  pustule.  Early  resection, 
five-year-old  girl.    Eecovery. 


Fig.  373. — Tuberculosis  of  the  neck  of  the  femur 
with  three  sequestra.  Secondary  tuberculosis 
of  the  hip-joint;  the  cartilage  of  the  head  of 
the  femur  is  destroyed.  Eesection  of  the  hip. 
Eight-year-old  boy  (Volkmann). 


so-called  infarcts — i.  e.,  the  necrosis  of  tissue  resulting  from  occlusion  of 
the  terminal,  afferent  arterial  vessel.  These  infarcts  have  the  form  of 
a  wedge  which  corresponds  to  the  distribution  of  the  terminal  branches 

of  the  affected  vessels.  The 
cuneiform  sequestra  which 
are  met  with  in  tuberculosis 
of  bone  are  probably  due  in 
the  same  way  to  the  plugging 
of  the  terminal  artery  at  the 
apex  of  the  wedge  with  tu- 
bercle bacilli.  If  the  tuber- 
culosis begins  in  the  bone  the 
articular  cartilage  either  be- 
comes perforated  like  a  sieve 
by  the  tubercular  inHamma- 
tion,  or  it  is  raised  from  the 
underlying  parts  more  or  less 
in  toto,  as  in  Fig.  372.  In 
/  the  later  stages  large  portions 

of  articular  cartilage  may  be 

Fig.  374.— So-called  wandering  of  the  acetabulum  in  j.    j      •        j   .t       x  a1 

coxitis  (-'intraacetabuliire  Luxation").  Separated     tn     tOtO    irom     tlie 


§  114.] 


THE  CHRONIC  INFLAMMATIONS  OF  JOINTS. 


G7.^. 


•375. — Tubercular  kyphosis  of  the  vertebral 
column  ( Sayre). 


bone,  or  the  cartilage  may  l)e  completely  destroyed,  as  in  Fig.  373. 
It  is  very  fortunate  for  the  patient  if  the  tubercular  process,  for  exam- 
ple, in  the  epiphysis  of  a  long,  hollow  bone  does  not  attack  the  joint 
but  breaks  through  externally 
to  it.  This  extra -articular 
breaking  through  of  bone  tu- 
berculosis in  the  neighbourhood 
of  a  joint  is  a  rather  common 
occurrence.  After  the  tuber- 
cular inflammation  of  the  joint 
has  broken  through  the  joint 
capsule  there  follows  a  develop- 
ment of  periarticular  tubercular 
inflammation  and  suppuration 
with  extensive  collections  of 
pus — the  so-called  congestion, 
cold,  or  gravitation  abscesses 
which  we  have  spoken  of  in  a 
previous  chapter.  Xot  infre- 
quently the  extra-articular  tu- 
bercular abscesses  originate  by 
infection  through  the  lymph  channels  without  a  rupture  of  the  capsule 
having  taken  place,  and  without  the  existence  of  any  visible  communi- 
cation between  the  intra-  and  extra-articular  suppurative  processes.  If 
the  lymph  glands  connected  with  the  joint  become  infected  by  tuber- 
culosis, the  danger  of  the  tubercle  bacilli  being  carried  further — in 
other  words,  the  danger  of  a  general  tuberculosis — becomes  more  im- 
minent. Very  often  the  tubercular  inflammation  works  its  way  out- 
wards through  the  skin  spontaneously,  and  gives  rise  to  fistulse  which 
frequently  pass  a  long  distance  through  soft  parts  and  bone. 

The  destruction  of  tissue  which  takes  place  in  tubercular  arthritis, 
and  is  the  result  of  the  progressive  change  of  bone,  cartilage,  and  soft 
parts  into  tubercular  granulation  tissue,  which  breaks  down  and  undergoes 
cheesy  degeneration  and  suppuration,  is  sometimes  very  considerable. 
The  entire  head  and  neck  of  the  femur  may  thus  be  destroyed  by  caries 
and  necrosis,  and  not  infrequently  extensive  ulcerative  processes  lead  to 
perforation  of  the  acetabulum.  Very  often  the  latter  becomes  enlarged 
in  an  upward  direction,  and  the  head  of  the  femur,  following  the  change 
in  the  shape  of  the  acetabulum,  is  caused  to  assume  a  higher  position — 
a  phenomenon  which  is  called  "  wandering  of  the  acetabulum  -'  (Fig. 
374).  In  the  spinal  column  entire  vertebrae  may  be  destroyed,  giving 
rise  to  corresponding  deformities,  especially  kyphosis  or  Pott's  hump 


676 


INJURIES  AND   DISEASES  OF  JOINTS. 


(Fig.  375).    Furthermore,  in  tuberculosis  of  the  vertebrse,  the  cold,  con- 
gestion abscesses  which  gradually  burrow  downwards    may  attain  a 

considerable  size  ;  they  usually  follow 
the  course  of  the  ilio-psoas  muscle,  and 
may  eventually  come  to  the  surface  in 
the  thigh  beneath  Poupart's  ligament. 

If  left  to  itself  a  tubercular  focus 
may  heal  up  at  any  stage  of  its  exist- 
ence. Recovery  often  takes  place  only 
after  the  joint  has  become  completely 
obliterated  or  anchylosed,  but  not  in- 
frequently the  cure  is  only  apparent 
and  temporary.  If  the  joint  has  not 
been  inmiobilised  in  a  proper  position 
while  the  tubercular  disease  was  in 
progress,  contractures  are  very  liable  to 
take  place  ;  and  if  these  affect  the  knee 
or  hip,  the  use  of  the  leg  may  be  seri- 
ously' interfered  with  or  rendered  im- 
possible (see  Fig.  376). 

The  Development  of  Tubercular  Ar- 
thritis after  the  Injection  of  Tubercle  Ba- 
cilli into  the  Joints  of  Animals. — If  x^ure 
cultures  of  tubercle  bacilli  are  injected  into 
the  joints  of  guinea-pigs  there  will  be  ob- 
served, after  the  lapse  of  four  to  six  days, 
an  increasing  inflammatory  swelling  and 
exudation  into  the  joints  under  consider- 
ation, and  towards  the  end  of  the  third  week  the  presence  of  tubercle  bacilli 
can  be  plainly  made  out,  and  pus  will  be  found  in  the  joints.  Pawlowsky 
states  that  the  tubercle  bacilli  are  located  mainly  in  the  lymph  passages  and 
connective-tissue  cells.  If  intravenous  injections  of  attenuated  (weakened) 
cultures  of  tubercle  bacilli  are  practised  in  rabbits,  the  typical  picture  of  tu- 
bercular disease  of  joints  will  sometimes  be  obtained  only  after  four  to  five 
to  six  months,  while  the  other  organs  will  remain  healthy  (Courmont,  L. 
Dor). 


Fig.  376. — Tubercul.ir  contracture  and 
anchylosis  of  the  knee  of  a  six-year- 
old  Vjoy.  Cuneiform  resection  fol- 
lowed by  healing  in  the  extended 
po.sition. 


Tubercular  arthritis  runs  an  exceedingly  chronic  course,  as  a  rule, 
and  often  la.sts  many  years.  The  disease  mo.st  commonly  attacks  chil- 
dren, though  adults  of  all  ages  are  not  exempt  from  it.  The  joints 
most  frequently  affected  are  the  knee,  the  hip,  the  astragalo-tibial 
joint,  and  the  joints  of  the  tarsus.  Tubercular  arthritis  generally  be- 
gins very  gradually,  but  in  rare  instances  is  more  or  less  acute  in  its 
onset.     The  first  symptoms  of  tuberculosis  involving  the  knee  joint 


t5  114.]  THE  CHRONIC   INFLAMMATIONS  OP  JOINTS.  677 

of  a  child,  for  example,  are  a  proneness  to  fatigue  and  a  slight  liinji 
or  dragging  of  the  leg  in  walking,  and  after  having  heen  on  its  feet  for 
some  time  ;  or,  if  pressure  he  made,  the  child  will  complain  of  pain 
in  the  joint.  The  tirst  ol)jective  symptom  is  generally  a  moderate 
amount  of  swelling,  which  causes  the  furrows  beside  the  patella  to 
become  less  plainly  marked  than  upon  a  healthy  knee.  The  ini- 
tial symptoms  manifested  by  joints  which  are  more  deeply  placed  are 
not  so  apparent  as  they  are  in  the  knee.  As  the  disease  progresses 
the  swelling  of  the  knee  gradually  increases,  and  the  normal  contour 
of  the  joint  disappears  to  a  greater  and  greater  extent.  The  swell- 
ing feels  rather  hard,  or  it  is  more  soft  and  spongy,  and  is  caused 
either  by  a  thickening  of  the  synovial  membrane  and  periarticular 
connective  tissue,  or,  as  in  primary  osseous  tuberculosis,  by  enlarge- 
ment of  the  articular  ends  of  the  bones.  The  skin  is  ordinarily  more 
or  less  tense,  and  presents  a  white,  waxy  apj^earance,  which  gave  rise 
to  the  term  tumor  albus,  formerly  used  to  designate  this  condition. 
As  the  swelling  becomes  greater  the  pain  in  the  joint  increases,  and  is 
made  worse  by  pressure  and  attempts  at  motion.  The  pain,  however, 
is  not  always  felt  in  the  diseased  joint,  as  in  tubercular  inflammation  of 
the  hip  (coxitis),  for  example,  the  children  very  often  complain  of  pain 
in  the  knee,  which  might  lead  an  inexperienced  person  to  search 
for  the  disease  in  the  wrong  place.  This  pain  in  the  knee  accom- 
panying tubercular  coxitis  is  particularly  apt  to  be  present  when  there 
is  tubercular  disease  of  the  medulla,  the  pain  shooting  through  the  latter 
dowh  to  the  lower  epiphysis ;  the  phenomenon  used  to  be  looked  upon 
as  a  reflex  manifestation.  Standing  and  walking  eventually  become  im- 
possible, and  the  tubercular  inflammation  causes  the  joint  to  grow  more 
and  more  immovable.  The  knee  and  elbow  are  usually  flexed  to  a 
greater  or  less  extent,  and  the  hip  assumes  a  position  in  flexion,  abduc- 
tion, and  outward  rotation.  At  the  outset  the  abnormal  position  of  the 
joints  can  be  corrected  under  chloroform  anaesthesia,  but  later  this  can- 
not be  accomplished  without  operative  interference.  The  distorted 
positions  of  the  joints — the  contractures — may  sometimes,  as  a  result  of 
improper  treatment,  become  very  excessive,  as  illustrated  in  Fig.  876  ; 
but  contractures  like  this  can  always  be  easily  prevented  by  the  use  of 
retentive  dressings  applied  at  the  right  time. 

Attempts  have  been  made  to  explain  this  abnormal  position  as- 
sumed by  inflamed  joints  by  (1)  the  mechanical  theory  advanced  by 
Bonnet,  and  (2)  by  the  reflex  theory.  Bonnet  demonstrated  by  intra- 
articular injection  of  a  liquid  that  the  joint  thus  treated  assumes  a 
position  in  which  its  capacity  is  greatest — i.  e.,  increasing  its  contents 
forces  a  joint  like  the  knee  to  become  flexed.    According  to  the  second 


g-j-g  INJURIES   AND   DISEASES   OF  JOINTS. 

theory,' a  reflex  muscular  contracture  is  produced  by  the  irritation  of 
the  synovial  membrane.  Both  theories  are  right  as  far  as  they  go,  but 
bv  themselves  are  not  suflicient  to  answer  the  question — a  fact  which 
Volkmann  has  correctly  insisted  upon.  It  must  be  borne  in  mind  that 
the  patient  instinctively  places  his 'joint  in  a  position  which  diminishes 
the  pressure  on  the  joint  surfaces  and  causes  him  the  least  pain.  More- 
over, the  mechanical  conditions  connected  with  the  use  of  the  diseased 
extremity,  the  longitudinal  growth  of  the  bone,  and  subsequently  the 
changes  which  take  place  in  the  shape  of  the  articular  ends  of  the 
bones,  have  an  influence  upon  contractures  (see  pages  549  and  554). 

The  further  course  of  tubercular  arthritis — sometimes  called  the 
second  stage  of  the  affection — is  characterised  by  an  increase  of  all  the 
pre-existing  symptoms,  especially  the  swelling,  flxation,  and  pain,  and, 
in  addition,  there  are  very  often  manifestations  of  suppuration  in  the 
joint ;  in  other  words,  a  high  fever  develops,  the  joint  becomes  very 
painful  at  some  particular  point,  and,  finally,  fluctuation  can  be  detected. 
Suppuration  in  the  joint  is  eitl\er  accompanied  by  inflammatory  mani- 
festations of  variable  intensity,  or  it  runs  its  course  as  a  cold  abscess. 
The  amount  of  pus  which  is  present  is  by  no  means  constant,  being  in 
some  instances  very  considerable,  while  in  others  the  formation  of  pus 
is  slight,  although  the  destruction  of  the  articular  ends  of  the  bones 
may  be  verv  marked.  Permanent  deformities  develop  in  consequence 
of  these  changes  in  the  bones,  as  well  as  the  so-called  pathological  or 
spontaneous  dislocations.  The  anatomical  changes  which  follow 
suppuration  in  a  joint,  the  development  of  periarticular  abscesses 
from  rupture  of  the  pus  in  the  joint  through  the  capsule  or  from 
infection  through  the  lymphatics,  the  occurrence  of  extensive  gravita- 
tion abscesses,  etc.,  have  all  been  described  above. 

The  patients'  general  condition  is  ordinarily  very  much  altered  for 
the  worse;  they  are  emaciated,  ansemic,  without  appetite,  and  not  infre- 
quently have  diarrhoea  and  more  or  less  fever. 

Tubercular  arthritis  terminates  either  in  recovery,  or  in  death  from 
systemic  tubercular  infection,  from  tuberculosis  of  the  internal  organs, 
especially  the  lungs  and  intestine,  from  increasing  marasmus,  from 
amyloid  degeneration,  or  from  some  intercurrent  disease.  Tubercu- 
losis is  the  most  common  cause  of  death.  Of  one  hundred  and  thirty- 
five  cases  of  tubercular  arthritis  which  ended  fatally,  Albrecht  states 
that  sixty-four  were  due  to  tuberculosis,  twenty-three  to  marasmus, 
and  fourteen  to  amyloid  changes  ;  while  in  thirty-four  the  cause  of 
death  was  unknown.  Billroth  maintains  that  the  danger  of  pulmonary 
tuberculosis  is  greater  after  tubercular  arthritis  occurring  in  the  upper 
extremity  than  when  the  disease  affects  the  lower. 


^114.]  TIIH   rURONIC   INFLAMMATIONS   OF   JOINTS.  679 

As  a  general  thing  it  requires  a  very  long  time,  often  years,  for 
recovery  to  take  place  spontaneously  from  tubercular  arthritis.  In 
such  cases  there  is  a  gradual  abatement  of  the  local  manifestations,  the 
general  health  improves,  and  any  fistulae  which  may  be  present  close 
up.  AVhen  spontaneous  recovery  takes  place  from  a  pronounced  tuber- 
cular arthritis  with  iistula?,  the  joint  which  has  been  affected  always 
becomes  stiff.  If  no  appreciable  suppuration  has  occurred,  recovery 
not  infrequently  follows  without  operative  interference  and  with  per- 
fect motion  in  the  joint  in  question.  It  is  scarcely  possible  to  say 
with  certainty  when  joints  which  have  been  affected  by  tuberculosis 
have  gotten  entirely  well,  for  relapses  have  taken  place  even  after 
anchylosis  has  existed  for  years.  With  the  modern  methods  of  per- 
forming surgical  operations  we  are  able  to  gi\e  a  more  favourable 
prognosis,  both  as  regards  the  preservation  of  the  joint  and  the  life  of 
the  patient.  Xevertheless,  the  prognosis  of  tubercular  arthritis,  as 
Billroth  has  remarked,  is  in  so  far  unfavourable  as  such  individuals  do 
not  reach  an  advanced  age.  There  are,  for  example,  only  compara- 
tively few  people  with  anchylosis  due  to  tuberculosis  who  live  to  be 
more  than  forty  or  fifty  years  old ;  and  Billroth  says  that  onlv  the 
minority  of  children  who  have  been  operated  upon  for  tubercular 
caries  of  a  j"int.  and  cured,  attain  adolescence. 

Treatment  of  Tubercular  Arthritis. — The  therapy  of  tubercular  ar- 
thritis comprises  local  treatment  of  the  diseased  joint,  and'^measures  de- 
signed to  improve  the  general  health  and  render  the  system  capable  of 
successfully  carrying  on  the  struggle  for  existence  with  the  tubercle  ba- 
cilli. This  constitutional  treatment  is  described  on  pages  420  and  424 
(Constitutional  Treatment  of  Tuberculosis  and  Scrofula). 

Inasmuch  as  tubercular  arthritis  gets  well,  though  very  slowlv.  under 
proper  local  and  constitutional  treatment  without  operative  interfer- 
ence, it  would  be  entirely  wrong  to  immediately  subject  every  case  of 
tuberculosis  of  joints  to  operation.  Therefore,  at  the  beginning  of  the 
tubercular  arthritis,  the  local  treatment  should  be  directed  towards  se- 
curing absolute  rest  for  the  joint  by  means  of  hardening  dressings  (see 
§  54,  plaster  of  Paris,  water-glass ),  or  some  of  the  various  kinds  of  splints 
(see  §  53),  or  by  permanent  extension  (see  §  55),  the  latter  being  par- 
ticularly applicable  for  the  hip.  Sayre  and  Taylor  have  invented  in- 
genious extension  appliances  for  the  lower  extremity  which  enable  the 
patient  to  walk  about.  It  is  also  very  advantageous  in  the  case  of  cox- 
itis to  place  a  raised  sole  under  the  foot  of  the  sound  side,  and,  by  using 
crutches  to  walk  with,  thus  keep  in  suspension  the  diseased  leg,  which 
should  be  maintained  in  a  fixed  position  by  Thomas's  splint  (see  Spec. 
Chir.,  Bd.  II,  p.  623).     Hydropathic  applications  or  ice  may  also  be 


^80  INJURIES   AND   DISEASES  OF  JOINTS. 

employed  for  acute  or  subacute  exacerbations  which  are  accompanied 
bj  pain.  If  contractures  of  the  joints  are  ab'eady  present  when  the 
case  comes  under  observation,  they  must  be  gradually  overcome  Ijy  re- 
tentive (see  page  218)  or  extension  dressings,  often  with  the  aid  of  chlo- 
roform anaesthesia.  Great  care  must  be  taken  in  correcting  the  posi- 
tion of  a  joint  which  has  become  distorted  ;  it  will  often  be  impossible 
to  remedy  matters  all  at  once,  and  the  desired  result  will  have  to  be  ac- 
complished gradually  in  several  sittings.  Each  time  that  the  contrac- 
ture is  improved  the  joint  should  be  immediately  fixed  in  its  new  posi- 
tion by  a  plaster-of- Paris  dressing.  Massage  should  never  be  practised 
at  the  beginning  of  a  tubercular  arthritis,  as  I  have  repeatedly  seen  se- 
vere constitutional  tubercular  infection  caused  by  quacks  who  have  pre- 
scribed it. 

Injections  of  sterilised  ten-per-cent.  iodoform  oil  or  ten-per-cent. 
iodoform  glycerin  (Bruns)  are  exceedingly  valuable  at  the  commence- 
ment of  the  tubercular  inflammation  of  a  joint,  and  later  on  when  fistulie 
have  developed.  The  manner  of  preparing  and  sterilising  the  iodoform- 
oil  emulsion  is  described  on  page  626.  According  to  the  age  of  the 
patient  and  the  size  of  the  afliected  joint,  about  every  two  to  four  weeks 
from  two  to  five  to  ten  grammes  of  the  above  mentioned  mixture  are 
injected  into  the  joint  and  scattered  through  the  latter  as  far  as  pos- 
sible by  careful  motion  and  gentle  massage.  I  have  seen  very  remark- 
able success  obtained  by  these  iodoform  injections.  Injections  of  car- 
bolic acid,  of  a  strong  solution  of  chloride  of  zinc  (Lannelongue),  and  of 
arsenic  (acid,  arsen.  1  to  1,000,  and  of  this  one  to  two  hypodermic 
syringefuls  each  day,  combined  with  the  internal  administration  of 
O'OOlr  to  0*012  gramme  arsenic  pro  die\  of  iodoform  ether,  balsam  of 
Peru,  cinnamic  acid  (see  page  420),  etc.,  have  also  been  recommended. 

The  treatment  of  tubercular  arthritis  by  Koch's  tuberculin  has  been 
discussed  on  page  421.  I  have  not  seen  any  satisfactory  results  from 
its  use.  Bier's  treatment  by  constriction  for  the  purpose  of  causing 
stasis  is  described  on  page  421,  and  the  other  methods  for  treating  tu- 
berculosis in  §  83. 

It  is  not  always  an  easy  matter  to  decide  whether  operative  meas- 
ures are  necessary,  for  the  simple  reason  that  one  cannot  always  be  sure 
of  the  exact  nature  of  the  pathological  changes  which  are  present — a 
matter  which  Konig  is  right  in  calling  attention  to.  In  former  times, 
when  the  antiseptic  method  of  treating  wounds  was  first  introduced, 
surgeons  went  too  far  and  performed  resections  of  joints  too  often,  par- 
ticularly in  the  case  of  children  who  suffered  from  tubercular  arthritis. 
But  at  present  conservative  treatment  is  employed  as  much  as  possible, 
and  many  joints,  which  would  formerly  have  been  sacrificed  by  per- 


§114.)  THE   CHRONIC   INFLAMMATIONS   OF   JOINTS.  681 

forming  total  resection,  are  now  saved  by  iodoform  injections,  by  exci- 
sion of  tlie  synovial  membrane,  or  by  scraping  away  the  diseased  tissue. 
Ricliet,  Koclier  and  Vincent  have  recommended  ignipuncture  or 
punctiform  ustion  made  with  the  fistula  tip  of  the  Paquelin  cautery 
or  with  the  galvano-cautery.  I  believe  that  this  procedure  is  suitable 
for  tuberculosis  of  the  synovial  membrane  which  has  not  become  too 
extensive ;  but  after  the  fungous  granulations  have  passed  into  the 
stage  of  suppuration  energetic  operative  measures  are  required.  The 
joint,  after  being  artificially  made  bloodless,  is  opened  and  the  diseased 
parts  then  removed  with  great  care  by  means  of  scissors,  forceps,  and 
the  sharp  spoon  ;  but  ty  |)ical  resection  of  the  articular  ends  of  the  bones 
should  be  performed  only  in  extreme  cases  (see  §  40).  If  the  tubercu- 
losis is  purely  of  the  syno\'ial  variety,  and  the  bones  are  healthy,  we 
should,  of  course,  preserve  the  latter  and  content  ourselves  with  exci- 
sion of  the  diseased  membrane  (arthrectomy).  Early  as  well  as  late 
resection  of  all  children's  joints,  with  the  exception  of  the  hip,  should 
be  confined  to  as  small  a  number  of  cases  as  possible  ;  energetic  scrap- 
ing away  of  the  diseased  bone  with  the  sharp  spoon,  but  sparing  the 
epiphysis,  or  extirpation  of  the  diseased  synovial  membrane,  but  leav- 
ing the  bone  untouched  or  removing  some  of  the  cartilage,  will  almost 
always  be  found  sufticient.  By  performing  early  arthrectomy  with 
preservation  of  the  articular  ends  of  the  bones  in  their  entirety,  or  as 
much  of  them  as  possible,  a  permanent  cure  can  often  be  obtained,  and 
that,  too,  with  a  movable  joint,  a  fact  which  is  attested  by  Angerer's 
numerous  cases.  Amputation  is  only  permissible  in  cases  where  the 
saving  of  life  comes  into  the  question,  where  the  destructive  processes 
have  become  very  extensive,  or  where  the  patient  cannot  survive  the 
long  period  of  time  required  for  a  resection  to  heal.  Other  compli- 
cations are  treated  according  to  the  general  principles  which  apply 
to  them.  Cold  abscesses  can  with  impunity  be  freely  opened,  thor- 
oughly scraped  out  and  drained.  It  is  very  important  to  recognise  a 
tubercular  focus  in  the  neighbourhood  of  a  joint  before  it  breaks 
through  into  the  latter,  and  to  remove  it  with  the  sharp  spoon.  After 
every  operation  for  tubercular  arthritis  the  wound  should  be  disin- 
fected as  carefully  as  possible  to  prevent  infection  with  bacilli  from 
the  wound.  Iodoform  and  iodoform  gauze  seem  to  be  the  most 
suitable  dressing  materials,  especially  for  packing  the  joint.  When  a 
tubercular  inflammation  of  a  joint  has  got  well,  some  suitable  splint 
apparatus,  such  as  one  of  those  devised  by  Sayre,  Taylor,  or  Thomas, 
should  be  worn,  especially  on  the  lower  extremity,  to  support  the  limb, 
which  will  still  be  weak.  If  any  abnormal  conditions,  such  as  con- 
tractures, follow  a  tubercular  arthritis,  they  may  have  to  be  treated  by 


gS2  INJURIES  AND   DISEASES   OF  JOINTS. 

tenotoftij  of  the  shortened  muscles — or.  rather,  tendons — by  resection, 
arthrotomy,  or  by  a  wedge-shaped  osteotomy,  below  the  trochanter, 
for  example,  when  the  contracture  involves  the  hip,  unless  they  can  be 
stretched  under  anaesthesia  or  gradually  overcome  by  extension  or  re- 
tentive appliances  (see  page  216). 

The  treatment  of  tuberculosis  of  the  individual  joints  will  be  de- 
scribed in  the  Special  Surgery.  7 

V.  The  Syphilitic  Diseases  of  Joints  (see  also  §  84,  Syphilis,  and  page 
628,  Svphilis  of  Eone;. — The  syphilitic  diseases  of  joints  have  lately 
been  frequently  and  accurately  described  by  such  men  as  Schiiller, 
Gies,  Falkson,  etc.,  and  their  occurrence  can  be  readily  understood  if 
we  bear  in  mind  that  syphilis  is  a  specific  infectious  disease.  The 
joints  become  affected  in  the  course  of  syphilis,  sometimes  primarily 
and  sometimes 'secondarily,  after  syphilitic  disease  in  the  surrounding 
parts,  particularly  the  periosteum  and  medulla.  The  syphilitic  inflam- 
mations of  joints  may  be  met  with  during  the  early  stages  of  the  dis- 
ease at  the  time  of  the  febrile  eruption,  or  during  the  later  periods. 
The  early  forms  are,  in  the  main,  serous  synovites,  which  occasionally 
make  their  appearance  in  a  manner  analogous  to  acute  polyarticular 
rheumatism.  The  inflammations  of  joints  which  occur  in  the  later 
stages  of  syphilis  have,  as  a  rule,  a  pronounced  chronic  character,  and 
are  generally  connected  with  the  formation  of  gummatous  deposits  in 
the  periosteum,  the  medulla,  and  the  synovial  membrane.  After  the 
gummatous  nodules  have  come  to  the  surface  and  ruptured  externally 
characteristic  ulcerations  occasionally  develop.  In  these  late  syphi- 
litic inflammations  of  joints  there  will  frequently  be  found  in  the  joint 
a  gummatous  or  carious  destruction  of  the  bones  and  sharplv  defined 
circumscribed  losses  of  substance,  or  radiating,  glistening  white  cica- 
trices in  the  cartilage,  together  with  fibrillation  of  the  latter,  while  in 
.  other  instances  a  connective-tissue  growth  in  the  synovial  membrane, 
taking  the  form  of  indurations  or  of  villi,  may  be  more  prominent. 
The  pathological  changes  at  the  first  glance  sometimes  look  like  those 
which  occur  in  arthritis  deformans.  Many  cases  run  a  course  with  a 
very  gradual  increase  in  the  amount  of  swelling,  and  resemble  clinic- 
ally tumor  albus,  but  the  pathological  changes  are  very  dilferent  from 
those  of  tubercular  arthritis.  In  rare  instances  the  gummatous  nodes 
occur  in  the  synovial  membrane  in  a  miliary  form  and  may  be  macro- 
scopically  mistaken  for  tubercles,  and  then  only  a  microscopic  exam- 
ination and  other  manifestations  of  syphilis  which  may  be  present 
will  clear  up  the  diagnosis.  The  indjirated,  villous  connective-tissue 
growths,  the  losses  of  substance  and  the  cicatrices  in  the  cartilage, 
and  the  gummatous,  carious  destruction  of  bone  are  characteristic  of 


§114.] 


TIIK  CHRONIC   INFLAMMATIONS  OF  JOINTS. 


683 


syphilitic  disease  of  joints.  An  acute,  subacute,  or  clifonic  serous  ar- 
thritis may  also  occur  in  the  later  stages  of  syphilis,  and  primary  sup- 
purative inflammation  of  a  joint  will  be  encountered  in  rare  instances 
— for  example,  when  syphilis  is  complicated  with  gonorrhoea,  etc. 
— >  The  therapy  of  the  syphilitic  inflammations  of  joints  consists,  in 
the  first  place,  in  a' proper  local  treatment  conducted  according  to  the 
rules  which  have  been  given  for  diseases  of  joints,  and,  secondly,  in  a 
''general  antisyphilitic  treatment,  the  best  being  inunctions  of  ungt. 
hydrarg.  ciner.  (see  §  84,  Treatment  of  Syi)hilis). 

YI.  Arthritis  Deformans  or  Malum  Senile. — This  affection  is  in  every 
respect  tlie  opposite  of  tubercular  arthritis.  Suppuration  or  caries 
never  occurs.  The  disease  attacks  individuals  who  are  old  or  past  the 
prime  of  life,  and  almost  always  involves  several  joints.  As  a  rule,  it 
causes  deformities  in  the  joints,  which_very  gradually  become  more 
marked,  while  recovery — i.  e.,  a  complete  restitutio  ad  integrum — never 
occurs,  and  arrest  of  the  process  only  rarely. 

The  pathological  changes  which  take  place  in  arthritis  deformans 
consist  (1)  in  degenerative  processes  in  the  cartilage  and  bones,,  and  (2) 
in  hyperplasia  of  the  bones,  cartilage,  and  soft  parts.  A  fibrillation 
occurs  in  the  more  superficial  layers  of  the  ground  substance  of  the 
hyaline  cartilage,  while  a  localised  cracking  and  softening  are  produced 
in  the  deeper  layers  by  the  vascular  me- 
dullary spaces  of  the  underlying  bone 
pushing  their  way  into  the  cartilage. 
At  the  same  time,  particularly  at  the 
free  borders,  a  growth  of  cartilage  oc- 
curs taking  the  form  of  knob-like  tube- 
rosities, which  subsequently,  for  the 
most  part,  ossify  (Figs.  377,  379).  In 
consequence  of  the  degenerative  fibril- 
lation and  softening  of  the  cartilage 
(arthritis  chronica  ulcerosa  sicca)  the 
latter  may  completely  disappear,  expos- 
ing the  uncovered  bone,  which  then,  by 
the  friction  produced  in  the  movements 
of  the  joint,  develops  a  smooth,  polished 
surface  (Fig.  379,  a). 

The  degenerative  changes  which  take 
place  in  the  bone  consist  in  a  lacunar  absorption  and  inflammatory 
atrophy  of  the  bone  tissue,  for  the  most  part  subchondral.  The  atro- 
phy of  bone  is  occasionally  very  considerable,  and  may  lead  to  the  dis- 
appearance of  the  head  or  entire  neck  of  the  femur  (Figs.  377,  378). 


Fig.  377. — Coxitis  deformans :  head  ot 
the  femur  below  the  tip  of  the 
great  trochanter ;  neclv  of  the  fe- 
mur no  longer  jiresent  (Path,  col- 
lection in  Zurich — Volkmann). 


684 


INJURIES   AND   DISEASES  OF  JOINTS. 


Just  as  in  the  case  of  cartilage,  there  will  be  encountered  in  addition  to 
the  atrophy  a  new  formation  of  bone  which  is  sometimes  very  marked 
(Fio-s.  378,  379).     In  some  cases  the  atrophy  of  the  bone  predominates 

(Fig.  377),  in  others  the  new  for- 
mation of  bone  (Fig.  379).  These 
degenerative  and  hyperplastic 
changes  in  the  cartilage  and  hone 
re  very  characteristic  of  arriiritis 
deformans.  The  capsule  and  lig- 
aments of  the  joints  also  become 
thickened  and  afterwards  con- 
tracted, and  the  synovial  villi  be- 
come the  seat  of  an  active  "process 
of  proliferation.  Loose-joint  bod- 
ies (see  §  115)  are  very  frequently 
found  in  the  joint,  but  adhesions 
between  the  articular  surfaces  of 
the  bones  or  obliteration  of  the 
joint  by  newly-formed  connective 
tissue  almost  never  occur. 

The  joints  gradually  become 
so  deformed  by  these  changes  in 
the  articular  ends  of  the  bones 
and  by  the  thickening  and  shrink- 
ing of  the  capsule,  which  is  some- 
times the  seat  of  a  new  formation  of  bone,  that  motion  becomes  more 
or  less  limited  or  entirely  lost.  If  the  atrophic  changes  in  the  bones 
predominate  the  joint  may  become  abnormally  mobile  or  even  loose  and 
flail-like,  with  a  tendency  towards  subluxation  or  complete  dislocation 
(luxations  of  deformity,  as  they  are  called).  These  dislocations  cannot,  as 
a  rule,  be  kept  permanently  reduced  owing  to  the  deformities  of  the  head 
of  the  bone  and  the  socket,  and  in  the  case  of  dislocations  of  the  head 
of  the  femur  a  new  acetabulum  may  be  formed  on  the  ilium  (Fig.  380). 
Arthritis  deformans  is  most  commonly  observed  in  the  hip,  knee, 
elbow,  and  shoulder,  and  less  often  in  joints  of  the  fingers  and  verte- 
brae. In  the  vertebrae  the  atrophy  of  bone  may  cause  the  development 
of  spinal  curvatures,  especially  kyphosis,  while  the  new  formation  of 
bone  may  give  rise  to  osseous  union  between  the  different  vertebrae. 
Arthritis  deformans  is  either  monarticular  or  polyarticular.  If  monar- 
ticular, it  is  usually  located  in  a  large  joint,  while  the  polyarticular 
form  more  commonly  occurs  in  the  small  joints,  such  as  those  of  the 
fingers  or  toes,  etc. 


Fig.  S'^. — Arthritis  deformans  of  the  hip  joint: 
the  greatly  enlarged  head  of  the  femur  lies 
very  near  the  trochanter  owing  to  the  dis- 
appearance of  the  neck  (Path.  Institute  at 
Leipsic). 


§114.] 


THE   CHRONIC  INFLAMMATIONS  OP  JOINTS. 


685 


We  still  know  little  about  the  etiology  of  this  disease,  though  its 
anatomical  peculiarities  are  so  characteristic.  It  may  begin  spontane- 
ously^  or  follow  the  re- 
ception of  some  trau- 
mati.sm,  such  as  a  frac- 
ture  which  involves  the 
joint,  or  come  on  after 
some  such  infectious 
inflammati(jn  as  a  gon- 
orrhcjeal  ai-thritis,  or 
after  acute  polyarticu- 
la.r  rheumatism.  The 
patient's  occupation  or 
position  in  life  plays  no 
part  in  the  causation  of 
arthritis  deformans,  but 
his  age  probably  does. 
I  look  upon  this  affec- 
tion as  essentially  a 
senile  disorder  which, 
as  a  rule,  can  be  ti'aced 
to  some  exciting  cause, 
such  as  a  traumatism  or 
an  infection — it  is  rare- 
ly spontaneous  —  and 
gives  rise  to  character- 
isEc  atrophy  and  to  hyperplasia  of  the  cartilage  and  bone,  and  to  thick- 
ening and  contraction  of  the  capsule. 

The  clinical  course  of  both  the  monarticular  and  polyarticular  form 
of  arthritis  deformans  is  exceedingly  chronic,  and  it  is  not  an  uncom- 
mon thing  for  the  disease  to  last  twenty  to  thirty  years.  The  initial 
symptoms  are  those  of  a  chronic  arthritis  running  a  course  without 
fever,  and  consist  in  stiffness  of  the  joint,  particularly  in  the  morning 
hours,  in  slight  pains,  and  in  the  occurrence  of  crepitating  or  creaking 
sounds.  Later  on  the  deformities  of  the  articular  ends  of  the  bones  or 
of  the  entire  joint  become  prominent.  The  movements  of  which  the 
joints  are  capable  become  more  and  more  restricted,  or  the  opposite 
condition  may  exist,  the  joints  becoming  loose  and  flail-like.  Occa- 
sionally acute  inflammatory  symptoms  make  their  appearance,  consist- 
ing of  fever,  increased  tenderness  and  inflammatory  swelling  of  the 
joint,  and  an  acute  effusion  of  serum.  The  pain  may  be  excessive. 
Recovery  is  extremely  rare,  the  disease  ordinarily  growing  worse  very 


condyl.  ext.  condyl.  int. 

Fig.  379. — Arthritis  defoi-riians  oftlie  ritrht  knee-joint:  a,  pol- 
ished and  smooth  articular  surface ;  ^,  growth  of  bone 
and  cartilage;  <^,  fibrillation  of  the  cartilage;  unequal 
length  of  the  femoral  condyles,  giving  rise  to  pronounced 
genu  valgum  ;  the  tran.sverse  diameter  of  the  internal  con- 
dyle and  the  longitudinal  diameter  of  the  external  con- 
dyle are  shortened  (Path.  Institute  at  Leipsic). 


686 


INJURIES   AND   DISEASES   OF  JOINTS. 


gradually  until  it  is  terminated  by  death  from  some  intercurrent  affec- 
tion. 

Diagnosis. — The  very  chronic  course  of  the  disease,  the  absence  of 
suppuration  and  caries,  the  characteristic  deformity  of  the  joints,  the 

advanced  age  of  the  patient,  and 
the  history  of  some  predisposing 
cause,  are  important  factors  in  the 
diagnosis  of  arthritis  deformans. 

The  Treatment  of  Arthritis  De- 
formans.— The  sooner  arthritis  de- 
formans is  subjected  to  systematic 
treatment  by  massage  and  active 
and  passive  movements  of  the  joint, 
the  greater  is  the  possibility,  par- 
ticularly in  the  case  of  the  monar- 
ticular form,  of  arresting  the  fur- 
ther development  of  the  disease. 
In  addition  to  massage  and  me- 
thodical exercise  of  the  joint,  baths 
in  which  the  entire  body  is  im- 
mersed in  lukewarm  water,  or  sand 
baths,  mud  baths,  or  steam  baths, 
combined  with  cold  douches — in  short,  hydrotherapeutic  measures — 
are  especially  to  be  recommended.  The  use  of  hot  springs,  such  as 
Gastein,  "Wildbad,  "Wiesbaden,  Teplitz,  Eagatz,  etc.,  and  a  residence  in 
southern  climates,  are  also  exceedingly  serviceable.  Marked  disturb- 
ances of  function,  especially  in  the  upper  extremity,  can  be  improved 
by  performing  resection,  but  amputation  is  only  indicated  in  the  rarest 
instances,  where  the  changes  are  very  pronounced.  Resection  of  the 
joint  has  been  repeatedly  practised  for  severe  pain,  the  results  in  some 
cases  being  excellent,  and  in  others  entirely  negative  (Fock,  Kiister, 
Riedel,  etc.).  The  other  complications,  such  as  the  acute  exacerbations, 
dislocations,  or  flail-like  joints,  which  sometimes  occur,  are  treated  ac. 
cording  to  the  general  rules  which  apply  to  these  conditions.  The  in- 
ternal administration  of  drugs,  such  as  iodide  of  potassium,  aconite, 
quinine,  iron,  etc.,  is  of  little  use,  but  a  strengthening  mode  of  life  with 
nourishing  food,  fresh  air,  etc.,  is  very  important. 

The  Diseases  of  Joints  which  occur  in  Bleeders  (HcemopMIia  :  see  page  57). 
— Individuals  who  suffer  from  liEemophilia  are  sometimes  affected  by  various 
kinds  of  joint  diseases,  which  generally  take  on  a  serious  character  owing  to 
the  presence  of  the  constitutional  dyscrasia.  Leaving  out  of  consideration 
the  different  forms  of  inflammation  of  joints  which  occasionally  occur  in 


Fig.  380. — Fonnation  of  a  new  acetabulum 
(A)  ou  the  OS  ileum  after  a  dislocation 
from  arthritis  deformans  in  a  woman 
seventy  years  old ;  £^  remains  of  the 
original  acetabulum  (Gutsch). 


§115.]  JOINT   BODIES   OR  JOINT   MICE.  087 

bleeders  as  well  as  in  other  people,  there  is  left  a  certain,  definite  group  of 
joint  diseases  which  are  clinically  and  pathologically  peculiar  to  haemophilia, 
and  wliich  are  to  be  regarded,  so  to  speak,  as  a  symptom  of  this  disease. 
Konig  has  recently  described  "bleeder  joints  "  very  much  at  length,  and  I  can 
fully  confirm  his  statements.  These  typical  joint  diseases  which  are  met 
with  in  lu\?mophilia  are  characterised  by  the  presence  in  the  joint  of  an  effu- 
sion of  blood,  which  may  per.sist  in  an  unaltered  state  for  weeks  and  then 
gradually  grow  smaller,  and,  if  the  conditions  are  favourable  and  compres- 
sion is  employed,  may  eventually  entirely  disappear.  But  in  other  instances, 
particularly  if  the  disease  is  not  properly  treated,  the  eff^usion  of  blood  is 
added  to  by  fresh  haemorrhages,  the  joint  becomes  gradually  more  and  more 
damaged,  the  articular  cartilages  undergo  erosion  and  fibi'illation,  and  the 
joint  grows  constantly  stiffer,  finally  becoming  obliterated.  If  the  unfavour- 
able conditions  continue,  contractures  and  deformities  of  the  joints  develop. 
It  is  a  very  easy  matter  to  mistake  a  bleeder  joint,  particularly  during  the 
early  stages,  for  hydrops  tuberculosus.  Konig  lost  two  patients  from  haemor- 
rhage because  he  had  thought  the  articular  disease  was  tubercular  and  conse- 
quently undertook  extensive  operations.  In  making  the  diagnosis  of  a 
bleeder  joint  the  personal  history  of  the  patient  is  of  the  utmost  importance, 
for  the  reason  that  the  patients  or  their  parents  are  generally  aware  of  their 
bleeder  disease.  It  should  be  noted  that  it  almost  always  occui-s  in  young 
subjects,  the  large  effusion  of  blood  usually  develops  suddenly  from  some 
slight  traumatism,  pain  is  generally  absent,  and  several  joints  are  commonly 
affected,  some  being  in  the  early  and  othere  in  the  advanced  stages. 

The  treatment  of  recent  cases  consists  in  placing  the  limb  in  an  elevated, 
position,  in  immobilisation  and  compression  of  the  joint,  and  subsequently  in 
gentle  massage  and  passive  motion.  In  some  instances  the  joint  should  be 
punctm-ed  for  the  purpose  of  removing  the  effused  blood.  Massage  should  be 
used  cautiously  and  as  an  experiment. 

§  115.  Joint  Bodies  or  Joint  Mice  {Mures  Articulares), — By  joint 
bodies  or  the  so-called  joint  mice  (mures  articulares)  we  mean  bodies 
varying  in  structure  which  are  formed  within  joints  and  are  either  free 
or  attached  by  pedicles.  Joint  bodies  anatomically  consist  of  cartilage 
or  of  bone,  or  of  bone  with  a  cartilaginous  covering,  of  fibrous  connect- 
ive tissue,  of  fatty  tissue,  or  of  fnasses  of  fibrin. 

We  are  able  to  distinguish  etiologically  three  principal  kinds  of 
joint  bodies :  (1)  Concretions  made  up  of  fibrin,  (2)  joint  bodies  result- 
ing from  the  breaking  off  of  cartilaginous  or  bony  portions  of  the 
articular  ends  of  the  bones  or  intra-articular  ligaments  by  some  trauma- 
tism, and  (3)  growths  of  connective  tissue,  cartilage,  or  bone  which 
originally  are  pedunculated,  but  later,  as  a  result  of  atrophy  or  sudden 
rupture  of  the  pedicle,  become  free  joint  bodies. 

(/ '  The  fibrin  concretions — i.  e.,  the  fibrin  precipitated  from  the  synovia 
in  cases  of  chronic  hydarthros,  for  example — take  the  form  of  round, 
smooth,  or  irregularly  shaped  concrements,  usually  about  the  size  of  a 


€88  INJURIES  AND   DISEASES   OF  JOINTS. 

melon  seed  or  grain  of  rice,  which  often  occur  in  great  numbers. 
These  concrements,  from  their  similarity  to  grains  of  rice,  are  also 
called  rice  bodies  (corpora  oryzoidea).  Schuchardt  maintains  that  the 
rice  bodies  are  not  "  fibrinous  "  products  of  coagulation  formed  from 
the  thickened  contents  of  a  joint  or  tendon  sheath,  but  are  portions  of 
the  synovial  membrane  or  tendon  sheath  which  have  undergone  coagu- 
lation necrosis  (Weigert)  or  fibrinoid  degeneration  (Neumann).  Occa- 
sionally the  concrements  attain  a  considerable  size — that  of  a  hen's  egg, 
for  example,  or  larger.  Small  foreign  bodies,  such  as  needle  points, 
broken-ofP  synovial  villi,  a  blood-clot,  etc.,  have  been  found  in  the  in- 
terior of  the  concretions,  just  as  in  vesical  calculi. 

In  the  second  category  of  cases  the  free  joint  bodies  are  formed 
from  bony  or  cartilaginous  portions  of  the  articular  ends  of  the  bones 
or  intra-articular  ligaments  which  are  torn  from  their  attachments  by 
some  traumatism,  such  as  a  blow,  a  fall,  or  some  other  violence.  These 
may  be  increased  in  size,  partly  by  deposits  of  fibrin  from  the  synovia 
and  partly  by  the  independent  growth  of  the  cartilage  or  medullary 
cells  which  they  contain.  Occasionally  the  detachment  is  not  complete, 
and  then  at  some  later  period  there  takes  place  a  gradual  or  sudden 
separation  of  the  partially  detached  piece  of  bone  or  cartilage.  Krage- 
lund  was  able  only  by  using  a  great  amount  of  force  to  partially  or 
completely  break  off  from  the  femur — generally  the  internal  condyle — 
but  not  from  the  tibia,  portions  of  bone  which  presented  a  close  simi- 
larity to  mures  articulares,  and  Poncet  saw  small  fragments  of  bone 
torn  from  the  points  where  the  ligaments  were  attached. 

Furthermore,  without  the  reception  of  any  traumatism  or  injury, 
larger  or  small  pieces  may  become  separated  from  the  articular  ends  of 
the  bones  as  a  result  of  some  process  which  is  not  as  yet  understood ; 
these  pieces  are  then  covered  on  their  bony  surfaces  with  dense  connect- 
ive tissue  which  contains  cartilage  cells,  and  the  loss  of  substance  in 
the  bone  from  which  they  came  is  repaired  in  a  similar  manner. 
Konig  has  given  the  name  of  osteochondritis  dissecans  to  this  genetically 
obscure  and  circumscribed  disease  of  the  articular  ends  of  the  bones. 
(3/  The  third  way  in  which  joint  bodies  may  originate — i.  e.,  in  the  form 
of  steadily  enlarging  growths  of  tissue  attached  by  a  pedicle  to  some 
part  of  the  articulation,  such  as  the  villi,  the  synovial  membrane,  or 
the  articular  cartilages — is  met  with  especially  in  chronic  joint  diseases, 
such  as  arthritis  deformans,  or  liydarthros  chronicus,  or  after  fractures 
which  involve  the  joint.  The  growths  are  made  up,  according  to  the 
point  from  which  they  spring,  of  connective  tissue,  cartilage,  or  bone, 
or  bone  with  a  cartilaginous  covering,  and  then  by  gradual  atrophy  or 
by  sudden  rupture  of  the  pedicle  these  growths  become   free  joint 


gll5.]  JOINT  BODIES  OR  JOINT   MICE.  689 

bodies.  In  tliis  category  belong  the  free  joint  bodies  formed  by 
growth  of  the  synovial  villi  or  by  fibrillation  of  tlie  cartilage,  as  well  as 
those  which  result  from  the  detachment  of  tumours  of  cartilage  or  bone 
(enchondroma  osteoma),  or  of  the  cartilaginous  or  bony  plates  in  the 
synovial  membrane  which  may  develoj)  in  the  course  of  liydarthros  and 
arthritis  deformans.  As  a  result  of  the  fibrillation  of  the  articular 
cartilage  occurring  in  a  chronic  arthritis,  there  is  often  a  very  excessive 
formation  of  cartilaginous  villi  in  which  a  vigorous  circumscribed 
growth  of  cartilage  cells  sometimes  takes  place.  If  these  formations 
become  loose,  hyaline  rice  bodies  analogous  to  the  above-mentioned 
fibrinous  rice  bodies  develop,  having  exactly  the  same  form  as  the  latter, 
and  likewise  existing  in  very  great  numbers.  The  condition  in  which 
there  is  an  excessive  growth  of  fat  in  the  villi  is  called  lipoma  arhores- 
cens,  and  may  give  rise  to  the  formation  of  free  joint  bodies  which  are 
soft  and  made  up  of  fat.  The  cartilaginous  and  bony  joint  bodies 
vary  greatly  in  size,  some  being  not  larger  than  a  bean  or  almond,  while 
others  are  as  large  as  the  patella.  Billroth  states  that  a  joint  body  has 
been  preserved  in  the  museum  at  Vienna  as  large  as  the  os  calcis,  which 
was  found  attached  liv  a  pedicle  to  the  capsule  of  the  joint. 

Symptomatology  and  Diagnosis  of  Free  Joint  Bodies. — As  we  stated 
before,  joint  bodies  are  found  in  joints  which  are  either  otherwise  per- 
fectly healthy  or  are  the  seat  of  chronic  inflammation,  particularly 
chronic  hydarthros  and  arthritis  deformans.  The  knee  joint  is  the  most 
common  location  in  which  they  are  encountered,  while  of  the  other  joints 
the  elbow  comes  next.  The  symptoms  caused  by  free  joint  bodies  are, 
first  of  all,  a  sudden,  severe,  darting  pain,  experienced  during  some 
particular  movement  of  the  joint,  often  causing  the  patient  to  appear 
as  though  paralysed  and  to  fall  to  the  ground  in  a  faint.  These  pains, 
which  reappear  with  more  or  less  frequency,  are  particularly  likelv  to 
occur  when  a  moderate-sized,  freely  movable  joint  body  becomes  caught 
in  a  synovial  pouch  or  between  the  articular  ends  of  the  bones.  The 
attacks  of  pain  are  usually  followed  by  inflammatory  manifestations  in 
the  joint  of  greater  or  less  severity,  which  take  the  form  of  an  acute 
serous  synovitis. 

Diagnosis. — These  characteristic,  paroxysmal  pains  are  of  the  great- 
est importance  for  making  the  diagnosis  of  free  joint  bodies.  In  some 
instances  the  latter  can  be  felt.  Nevertheless,  one  can  be  deceived 
even  in  this,  and  I  once  mistook  a  commencing  circumscribed  tubercu- 
losis of  the  capsule  of  the  knee  joint  for  a  free  joint  body.  After 
opening  the  joint  and  extirpating  the  diseased  portion  of  the  capsule, 
recovery  took  place,  with  perfect  motion  in  the  joint.  The  most  diflfi- 
cult  cases  to  recognise  are  those  in  which  the  joint  bodies  exist  in 
44 


690  INJURIES  AND   DISEASES  OF  JOINTS. 

an   articulation  which   has  undergone   changes   due   to   arthritis   de- 
formans. 

Treatment. — The  best  treatment  for  free  joint  bodies  consists  in 
their  operative  removal  bj  aseptic  arthrotoniy.  The  body  having  been 
located  by  palpation,  an  incision  is  made  directly  down  upon  it,  where- 
upon it  is  pressed  through  the  opening  thus  made  and  the  borders  of 
the  wound  are  immediately  closed  by  sutures.  The  joint  is  then  im- 
mobilised as  completely  as  possible  with  an  antiseptic  protective  dree- 
ing, over  which  splints  are  placed.  If  the  patient  is  afraid  of  the 
knife,  or  if  the  condition  does  not  cause  him  much  trouble,  we  recom- 
mend the  wearing  of  an  elastic  cap  around  the  joint,  to  afford  the  latter 
a  certain  amount  of  support  and  prevent  too  free  motion.  In  those 
cases  where  the  symptoms  indicate  beyond  a  doubt  the  presence  of  a 
joint  body,  but  where,  as  in  the  elbow,  it  cannot  be  reached  by  an  in- 
cision made  directly  down  upon  it,  in  case  the  patient's  discomfort  is 
great  enough,  the  joint  should  be  laid  freely  open  with  the  strictest 
aseptic  precautions,  and,  if  necessary,  a  partial  (temporary)  resection 
undertaken  to  render  it  possible  to  remove  the  joint  body. 

Exostosis  Bursata  with  Joint  Bodies. — Berg-mann  operated  upon  an  exos- 
tosis on  the  outer  aspect  of  the  lower  end  of  the  femur,  just  above  tlie  knee, 
which  was  surrounded  by  a  capsule  containing  upwards  of  five  hundred  rice 
bodies  made  up  of  hyaline  cartilage.  The  exostosis  probably  originated 
intra-articularly  as  an  ecchondrosis  of  the  articular  cartilage,  and  derived  a 
true  synovial  sac  by  pushing  before  it  the  capsule  of  the  joint,  the  divertic- 
ulum thus  formed  becoming  afterwards  completely  shut  oflF  from  the  joint. 
In  other  instances  the  exostosis  has  been  found  still  in  the  joint,  as  in  a  case 
of  Volkmann's,  where  it  was  attached  to  the  portion  of  the  semilunar  carti- 
lage which  adjoins  the  capsule.  In  this  case  there  were  in  addition  three 
bodies  lying  free  in  the  joint  (see  Exostoses,  §  128). 

§  116.  Neuroses  of  Joints  (Neuralgias  of  Joints;  Nervous,  Hysterical 
Diseases  of  Joints). — The  nervous  or  hysterical  affections  of  joints,  the 
neuroses  or  neuralgias  of  joints,  were  first  described  by  the  celebrated 
English  surgeon  Brodie,  and  his  statements  have  been  confirmed  by 
such  German  surgeons  as  Stromeyer,  Esmarch,  and  Erb  ;  while  quite 
recently  N^ewton  M.  Shaffer  has  written  an  exhaustive  treatise  on  the' 
subject.  Xo  pathological  changes  can  be  made  out  in  joints  which  are 
the  seat  of  neuralgias.  The  knee  and  hip  are  the  ones  most  commonly 
affected,  and  usually  one  joint  at  a  time,  rarely  two  or  more.  Females 
with  an  over-excitable  nervous  system,  or  who  are  markedly  hysterical, 
especially  young  girls  of  the  better  classes  of  society,  are  particularly 
apt  to  suffer  from  these  troubles,  and  hence  the  term  hysterical  joint 
affection.     But  the  disease  is  occasionally  met  with  even  in  perfectly 


§11(5. J  NEUROSES   OF  JOINTS.  G91 

healthy  men  and  women.  Amorioj  tlie  exciting;  causes  may  be  mentioned 
traumatisms,  sut-h  as  l)ruises  and  sprains  (jf  the  joints,  irritation  of  or 
j)ressure  upon  the  nerves  in  the  nei<^hbourhood,  excessive  emotional 
disturbances,  and  takin<i;  cold.  Joint  neuralgias  also  occur  retlexly 
from  diseases  of  the  abdominal  viscera,  especially  the  female  sexual 
oi'gaiis,  and  from  diseases  of  the  central  nervous  system,  such  as  tabes. 

Symptoms  and  Course  of  Joint  Neuroses. — The  chief  symptom  of  a 
joint  neuralgia  or  neurosis  is  the  pronounced  pain  and  tenderness  in 
the  joint,  while  objectively  nothing  abnormal  can  be  made  out.  The 
pain  is  felt  especially  when  pressure  is  made  at  some  particular  point, 
or  when  the  joint  is  moved.  In  addition  to  these  tender  points,  there 
is  generally  a  pronounced  diffuse  hyperaesthesia  of  the  skin  over  the 
joint ;  but  in  rare  instances  there  may  be  anyesthesia.  Moreover,  the 
function  of  the  joint  in  question  is  disturbed — i.  e.,  the  patient  avoids 
moving  the  joint  because  of  the  pain,  and  keeps  it  rigid.  There  are 
also  observed  a  state  of  muscular  spasm.  Math  secondary  distortions 
of  the  joints  (contractures) ;  vasomotor  disturbances  (urticaria-like 
wheals,  alternate  flushing  and  blanching,  etc.) ;  tremor ;  a  marked 
feeling  of  weakness ;  atrophy  of  the  extremity  which  is  involved,  and 
now  and  then  paralyses.  The  stifl'ness  and  contractures  of  the  joints, 
which  may  take  the  form  of  nervous  club-foot  or  stiffness  of  the  hip, 
will  immediately  disappear  under  chloroform  anaisthesia,  and  while 
the  patient  is  in  this  state  the  joint  will  be  freely  movable.  The  verte- 
bral column,  especially  the  spinous  processes,  are  also  sometimes  tender 
on  pressure.  The  course  of  the  nervous  joint  affections  is  usually 
rather  tedious  and  very  variable.  If  the  nervous  system  is  otherwise 
normal,  recovery  generally  takes  place  after  the  lapse  of  a  longer  or 
shorter  time,  though  it  may  occur  suddenly  after  some  emotional 
excitement  or  after  some  energetic  movements  have  been  made  with 
the  joint.  In  cases  of  pronounced  hysteria,  or  diseases  of  the  nervous 
system,  the  patients  are  occasionally  doomed  to  be  confined  to  bed  for 
years,  and  in  such  instances  the  affection  is  often  incurable. 

In  making  the  diagnosis  of  a  hysterical  joint,  we  should  note  par- 
ticularly that  certain  symptoms  which  indicate  an  inflammation  of  the 
joint  are  absent,  and  that  the  contractures,  the  stiffness,  etc.,  disappear 
completely  under  chloroform  anaesthesia.  The  above-mentioned  mani- 
festations of  the  disease  are  so  characteristic  that  they  are  generally 
sufficient  to  establish  the  diagnosis.  Old  sprains  with  slight  intra- 
articular adhesions  have  sometimes  been  mistaken  for  joint  neuralgias ; 
but  cases  of  this  kind  can  be  cured  in  a  very  short  time  by  massage 
combined  with  forced  movements  of  the  joint. 

The  prognosis  is  favourable  in  the  case  of  individuals  who  are 


692  INJURIES  AND   DISEASES   OF  JOINTS. 

otherwise  healthy  ;  but  if  they  are  excessively  neurotic  and  hysterical, 
it  is  uncertain,  and  is  the  more  unfavourable  the  severer  the  nervous 
complications. 

Treatment. — The  treatment  of  nervous  joint  affections  is  directed 
first  of  all  towards  the  cause.  If  there  is  pronounced  neurasthenia, 
hysteria,  or  other  nervous  anomalies,  or  disease  of  certain  organs  (of 
the  sexual  organs,  constipation,  etc.),  these  conditions  must  receive 
careful  attention.  In  every  case  a  general  tonic  treatment  for  the 
nervous  system  by  cold-water  cures,  sea-bathing,  a  sojourn  in  the 
mountains,  and  removal  of  the  patient  from  his  business  and  family, 
are  very  much  to  be  recommended.  Treatment  of  a  psychical  nature  is 
also  very  valuable ;  while  unexpected  joy  or  sorrow  has  often  caused 
hysterical  joint  neuroses  to  disappear  suddenly  and  permanently.  The 
local  treatment  of  the  diseased  joint  comprises  massage  and  methodical 
exercise,  rubbing  with  cold  water,  and  electricity  (the  strong  faradic  or 
galvanic  current  passed  transversely  through  the  joint).  Morphine  or 
atropine  is  occasionally  given  in  the  form  of  subcutaneous  injections  if 
the  patient  is  otherwise  healthy  and  robust.  Quinine  and  arsenic, 
given  internally,  are  also  of  use.  For  the  contractures  and  the  weak- 
ness of  the  muscles  and  joints  we  employ  suitable  braces  or  splints 
which  will  enable  the  patient  to  move  his  limbs. 

Other  Joint  and  Bone  Neuralgias. — The  neuralgias  sometimes  occurring 
in  joints  and  boues  which  have  previously  been  the  seat  of  a  disease  like 
tubercular  arthritis,  or  which  make  their  appearance  in  the  course  of  syphi- 
lis, or  after  recovery  from  caries  and  necrosis,  or  in  general  occur  hi  old  bone 
cicatrices,  are  of  a  totally  difPerent  nature.  Pain  of  this  description  is  very 
apt  to  occur  in  syphilis,  or  in  ossifying  osteomyelitis  and  periostitis,  or  in 
sclerosis  of  bone.  The  treatment  of  these  joint  and  bone  neuralgias  depends 
upon  the  cause.  Warm  baths  and  the  bathing  cures  given  at  Teplitz,  Wies- 
baden and  Gastein  are  generally  very  useful.  The  pain  occurring  in  bones 
and  joints  which  have  been  at  one  time  diseased  may  sometimes  become  so 
severe  that  amputation  or  disarticulation  is  performed  at  the  patient's  own 
request.  Close  examination  of  the  bone  in  such  cases  reveals  nothing  which 
can  account  for  the  great  suffering,  but  we  do  find  that  individuals  thus 
affected  are  usually  neurotic  (Poncet,  Auday). 

Quite  often,  however,  these  neuralgias  are  due  to  circumscribed,  inflam- 
matory foci  concealed  in  the  bone  or  joint,  and  if  this  is  the  case  the  disease 
should  receive  its  appropriate  treatment.  Abnormal  adhesions  in  a  joint, 
such  as  may  occur,  for  example,  in  old  dislocations  which  have  been  im- 
properly treated,  may  give  rise  to  violent  pains,  which  can  be  quickly  stopped 
by  massage  and  exercise.  In  general,  neuralgias  of  joints  and  bones  follow- 
ing a  pre-existing  disease  are  most  commonly  the  result  of  syphilis  or  some 
nervous  disease ;  and  these  must  be  the  first  things  to  be  considered  in  the 
treatment. 

Sometimes  violent  pain  also  occurs  in  bones  which  are  otherwise  ap- 


§117.]  NEUROPATHIC    DISEASES   OF   BONKS   AND  JOINTS.  G93 

paicMitly  health}'  and  have  not  previously  been  diseased,  eoming  on  espe- 
cially after  takinj;'  cold,  and  in  neurotic  indivichials.  Wai'in  baths  and  the 
use  of  the  above  mentioned  hot  springs,  as  well  as  an  autineurotic  treat- 
ment, should  be  employed. 

§  117.  Neuropathic  Diseases  of  Bones  and  Joints. — Peculiar  neuro- 
patliic  alfcctioiis  of  the  bones  and  joints,  of  great  clinical  interest,  oc- 
cur in  the  course  of  diseases  of  the  nerves  and  spinal  cord,  especially 
tabes.  Charcot  was  the  first  to  describe  accurately  the  arthropathies 
which  nuike  their  appearance  during  the  course  of  the  grey  degenera- 
tion of  the  posterior  columns  of  the  cord  ;  and  while  Charcot,  Erb, 
Buzzard  and  other  neurologists  ascribe  the  arthropathia  tabidorunr  to 
direct  nervous  influences — in  other  woi-ds,  to  trophoneurotic  disturb- 
ances— Volkniann,  Leyden  and  Virchow  maintain  that  the  tabes 
merely  brings  about  unfavourable  conditions,  in  consequence  of  which 
certain  diseases  of  the  joints  occur  more  easily  and  frequently  than 
they  do  in  a  state  of  health,  and  run  an  unusual  and  malignant  course. 
The  main  predisposing  causes  in  tabes  of  inflammations  and  injuries 
of  the  bones  are  the  loss  of  sensibility — i.  e.,  the  anaesthesia  or  anal- 
gesia of  the  joints,  the  ataxia,  and  the  fragility  of  the  bones.  These 
factors  also  influence  very  materially  any  deforming  or  traumatic, 
acute  or  chronic  inflammation  occurring  in  a  person  suffering  from 
tabes  dorsalis.  The  softness  and  brittleness  of  the  bones  in  tabes  are 
well  known,  and  account  for  the  frequency  with  which  spontaneous 
fractures  take  place  in  patients  with  this  disease.  The  fragility  of  the 
bones  is  due  to  a  trophoneurotic  change  in  their  organic  ground  sub- 
stance, and  may  be  encountered  even  in  bones  which  are  apparently 
very  strong  and  compact.  The  bones  may  also  become  remarkably 
l)rittle  in  people  with  various  mental  diseases,  or  with  infantile  spinal 
paralysis,  progressive  muscular  atrophy,  leprosy,  etc.,  and  Neumann 
has  ascribed  the  changes  that  occur  to  an  affection  of  the  vasomotor 
system.  Czerny,  Rotter  and  others  have  lately  made  exhaustive 
studies  of  arthropathia  tabidorum  and  neuropathic  bone  and  joint 
affections  in  general.  The  question  of  the  relationship  between  these 
affections  and  the  sclerosis  of  the  posterior  columns  of  the  cord  and 
other  diseases  of  the  spinal  cord  and  peripheral  nerves  has  recently 
been  the  subject  of  animated  discussion,  but  as  yet  it  has  not  been 
positively  decided  whether  spinal  diseases,  such  as  tabes,  syringomyelia, 
etc.,  should  be  regarded  as  direct  causes  of  these  troubles,  which  Char- 
cot believes  them  to  be,  or  only  as  predisposing.  Charcot  has  lately 
adopted  the  view  that  they  are  due  to  certain  localised  processes  of 
disease  in  the  diaphyses  and  epiphyses. 

Cause  of  Arthropathia  Tabidorum. — As  before  stated,  the  anaesthesia 


g94  INJURIES   AND   DISEASES   OF  JOINTS. 

or  analgesia  of  the  joints  plays  a  most  important  part  in  the  produc- 
tion and  course  of  arthropathia  tabidorum.  The  neuropathic  affections 
of  the  joints  which  occur  in  tabes  begin  either  without  any  external 
cause,  or  they  follow  the  reception  of  some  traumatism  ;  and  as  the 
patients  feel  no  pain,  they  walk  about  while  their  joints  are  inflamed 
and  thus  make  matters  worse ;  they  wear  off  the  brittle  articular  ends 
of  the  bones,  as  it  were,  so  that  the  entire  astragalus,  for  example,  may 
by  degrees  completely  disappear.  A  tabetic  individual  with  a  fracture 
of  the  leg,  who  came  under  Yolkmann's  care,  could  produce  a  very 
marked  displacement  of  the  fragments  without  suffering  any  pain. 
The  analgesia  cannot  always  be  easily  recognised,  it  being  occasionally 
limited  to  the  more  deeply  situated  nerves  alone,  while  the  skin  is  even 
over-sensitive  to  the  slightest  irritation.  The  chronic  arthropathies 
which  occur  in  tabes  and  do  not  go  on  to  suppuration,  run,  as  a  rule,  a 
course  similar  to  arthritis  deformans  (see  page  683),  but  differ  from  the 
latter  in  the  fact  that  the  different  parts  of  the  joints  are  very  rapidly 
destroyed,  and  dislocations  and  spontaneous  fractures  are  of  frequent 
occurrence.  One  can  distinguish,  as  in  arthritis  deformans,  an  atrophic 
and  a  hypertrophic  form  of  arthropathies  as  well  as  a  monarticular 
and  a  polyarticular  form.  If  the  specific  excitants  of  inflammation — 
micro-organisms — gain  entrance  to  a  joint  of  this  kind  which  is  the  seat 
of  a  chronic  inflammation,  septic  or  even  gangrenous  inflammation 
running  a  ver}'  rapid  course  often  develops.  Hence  it  can  be  seen 
that  in  the  course  of  tabes  various  forms  of  arthritis  may  be  en- 
countered, some  acute  and  others  chronic,  and  either  suppurative  or 
non-suppurative  ;  but  the  characteristic  feature  of  the  inflammation  is 
that  it  is  always  greatly  modified  and  influenced  by  the  analgesia  and 
ataxia  which  are  present,  and  by  the  weakness  and  fragility  of  the 
bones.  The  knee  is  the  joint  most  commonly  affected,  although  the 
articulations  of  the  upper  extremity  do  not  always  escape.  Rotter  has 
collected  112  cases  of  joint  disease  occurring  in  74  patients  with  tabes ; 
of  these,  49  were  of  the  knee,  24  of  the  hip,  12  of  the  shoulder,  12  of 
the  tarsal  joints,  6  of  the  elbow,  4  of  the  ankle,  3  of  the  hand  and 
fingers,  and  2  of  the  temporo-maxillary  joint.  Both  knee  joints  were 
diseased  in  11  cases,  both  hips  in  7,  the  tarsal  joints  in  3,  and  the 
shoulder,  wrist,  and  finger  joints  were  symmetrically  affected  twice. 
In  Weizsacker's  statistics  of  109  cases,  72  occurred  in  men  and  37 
in  women.  The  knee  joint  was  affected  78  times,  the  hip  31,  the 
shoulder  21,  the  tarsus  13,  the  elbow  10,  the  ankle  9,  the  carpal  and 
temporo-maxillary  joints  twice,  and  the  vertebral  column  once.  The 
observations  of  Leyden,  Oppenheim  and  others  show  that  affec- 
tions of  the  joints   and   weakness   and   fragility   of   the   bones   may 


§  UT.J  NEL'KOPATIIIC   DISEASES   OP   BONES   AND  JOI^'TS.  C95 

oet'ur  in  both  tlie  earliest  and  the  most  advanced  stages  of  tabes  dor- 
salis. 

In  making  the  diagnosis  of  neuropathic  bone  and  joint  affections, 
the  cliaraeteristic  features  in  chi-onic  cases  are  tlie  existing  nervous  dis- 
orders, which  in  the  case  of  arthropathies  of  the  lower  extremity  is 
most  comnioidy  tabes,  and  of  the  upper  extremity  syringomyelia,  the 
analgesia,  the  pronounced  exudation,  and  the  marked  destruction  of  the 
articular  surfaces  of  the  bones ;  the  acute  cases  become  rapidly  worse. 
Czerny  is  right  in  calling  attention  to  the  fact  that  the  predisposition 
to  nervous  disorders  is  an  important  matter  from  a  medico-legal  stand- 
point— in  other  words,  should  be  taken  into  account  in  a  plaintiff  who 
brino^s  suit  for  damao-es. 

The  prognosis  of  the  tabetic  arthropathies  is  very  uncertain,  and 
depends  largely  upon  whether  the  joints  are  used  or  protected  and 
properly  treated,  whether  ataxia  exists,  etc.  If  proper  treatment  is 
received  (fixation,  orthopaedic  appliances,  etc.),  it  is  possible  for  the 
arthropathy  to  be  improved  or  arrested. 

Similar  neuropathic  affections  of  the  bones  and  joints  are  also  noted 
in  the  course  of  other  cerebral  and  spinal  diseases  and  are  due  to 
analogous  disturbances  of  innervation.  In  six  cases  of  neuropathic  joint 
disease  described  by  Czerny,  two  of  the  patients  suffered  from  tabes  and 
four  from  syringomyelia  (see  below).  If  the  upper  extremity  is  the 
seat  of  paresis  and  analgesia,  affections  of  its  joints  may  occur  which  run 
the  same  course  as  the  arthropathies  of  tabes;  there  may  also  be  a  grind- 
ing away  of  the  head  of  the  humerus  in  the  shoulder  joint,  spontaneous 
fracture  of  the  bones  of  the  forearm,  osteophytic  growths,  trophic  dis- 
turbances in  the  skin  (ulcers),  etc.  IN^europathic  contractures  are  dis- 
cussed on  page  701. 

The  Arthropathies  of  Syringomyelia.— The  arthropathies  coming  on  in 
the  course  of  syiiiigomyelia  mainly  attack  joints  of  the  upper  extremity,  for 
the  reason  that  the  primary  disease  is  for  the  most  part  localised  in  the  cer\'ical 
portion  of  the  spinal  cord,  and  they  occur  in  the  great  majority  of  instances 
in  men  of  advanced  age.  Traumatisms  play  a  predisposing  part  in  their  pro- 
duction. The  course  of  the  arthropathies  is  always  chronic,  not  infrequently 
lasting  for  years.  There  will  occasionally  be  observed  an  acute  exudation  in 
the  joint,  or  even  suppuration,  especially  if  there  has  been  some  injury  which 
on  account  of  the  analgesia  has  been  neglected ;  but  thei'e  seldom  occurs  such 
a  marked  destruction  of  the  joint  in  a  comparatively  short  time  as  in  tabes. 
The  changes  in  the  joints  are  more  like  those  of  arthritis  defomians,  with  the 
formation  of  intra-articular  and  periarticular  osteophytes,  with  ossification 
of  the  periarticular  soft  parts,  degeneration  of  the  muscles,  and  thickening, 
dilatation  and  relaxation  of  the  capsule,  with  secondary  spontaneous  disloca- 
tions. The  joints  are  analgesic,  and  sometimes  to  such  a  pronounced  degi'ee 
that  large  joints  can  be  resected  without  chloroform  (Czerny,  Sokoloffj.    TMs 


(596  •  INJURIES  AND   DISEASES  OP  JOINTS. 

analgesia  is,  luoreover,  the  chief  factor  in  furthering-  the  development  of  the 
disturbances  of  nutrition  which  are  present  in  the  joints  and  bones.  The 
bones  are  in  some  instances  abnormally  weak  (hence  the  spontaneous  frac- 
tures) and  in  others  remarkably  sclerotic.  The  termination  of  the  arthrop- 
athies which  occur  in  syringomyelia  is  governed  mainly  by  the  primary 
disease  in  the  spinal  cord,  and  also  by  the  amount  of  cai'e  the  patient  takes 
to  protect  his  joints  from  injuries  that  may  readily  give  rise  to  complicating 
periarticular  and  intra-articular  suppuration.  Under  favourable  conditions 
the  joint  affections  are  usually  very  protracted.  The  diagnosis  can  be  read- 
ily made  if  the  pathological  changes  and  the  clinical  course  are  taken  into 
consideration  together  with  the  analgesia  and  the  location  of  the  arthro- 
pathies in  the  upper  extremity.  The  treatment,  particularly  in  the  early 
stages,  consists  in  immobilising  the  joint,  though  later  on  suitable  operative 
measures  may  be  necessary,  as  they  are  in  tabes. 

The  treatment  of  the  neuropathic  inllamniations  of  joints,  particu- 
larly the  arthropathies  which  occur  in  tabes  and  syringomyelia,  com- 
prises proper  local  treatment  of  the  affected  joint  and  general  treatment 
of  the  neuropathy  which  is  the  primary  cause  of  the  trouble.  We  con- 
sider, as  Czerny  does,  that  firm  anchylosis  in  a  good  position  is  prefer- 
able to  a  loose  joint  which  is  rapidly  ground  to  pieces  by  friction,  and 
in  the  early  stages  it  would  be  proper  to  bring  about  artificial  anchylo- 
sis by  performing  arthrodesis  (see  page  133).  If  patients  with  the 
above-mentioned  diseases  of  the  spinal  cord  receive  a  sprain,  the  joint 
must  be  treated  by  immobilisation  and  subsequently  by  a  supporting 
apparatus.  Should  extensive  destruction  or  suppuration  of  the  joint 
occur,  the  question  of  arthrotomy,  resection  or  amputation  would  arise. 

§  118.  Anchylosis. — By  ancliylosis  (from  ajKuXo^i,  angular,  crooked) 
is  understood  an  immovable,  stiff  joint,  such  as  results  from  an  inflam- 
mation of  a  joint  which  has  run  its  course.  The  word  anchylosis  sig- 
nifies properly  an  angular  23osition  of  the  joint ;  but  this  conception  of 
the  term  has  in  course  of  time  been  entirely  given  up,  so  that  wdien  we 
speak  of  anchylosis  of  a  joint  we  mean  that  its  power  of  motion  has 
been  lost,  irrespective  of  whether  the  joint  has  become  fixed  at  an  angle 
or  in  a  straight,  extended  position.  If  a  joint  is  in  an  angular  position 
we  speak  of  it  as  a  contracture  (see  §  119).  Anchylosis — in  other  words, 
stiffness  of  the  joint — and  contracture  very  frequently  occur  in  com- 
bination. If  we  wish  to  differentiate  these  two  terms  more  exactly,  we 
may  say  that  anchylosis  signifies  a  complete  cessation  of  the  motility  of 
a  joint  brought  about  by  intra-articular  causes,  while  contracture  is  a 
limitation  of  motion  generally  due  to  pathological  changes  in  the  extra- 
articular soft  parts  (see  all  §  97  and  §  98,  Diseases  of  the  Nerves  and 
Muscles).  We  also  recognise  a  false  and  a  true  anchylosis  (anchylosis 
spuria  and  anchylosis  vera).     The  term  false  anchylosis  applies  to  those 


§118.]  ANCHYLOSIS.  697 

cases  in  which  apparently  immovable  joints  can  be  caused  to  move 
under  chloroform  ana'sthesia,  and  is  a  condition  which  is  observed  in 
tiie  course  of  acute  or  chronic  intianunations  of  joints,  or  as  a  result  of 
inflammatory  or  voluntary  nmscular  contraction,  or  in  hysterical  joint 
disorders,  etc. 

The  Causes  of  True  Anchylosis. — True  anchylosis  is  most  commonly 
due  to  the  development  of  a  firm  union  between  the  different  parts  of 
the  joint,  and  according  to  the  nature  of  the  tissue  forming  the  union 
between  these  parts  we  recognise  a  connective  tissue  (anchylosis  fibrosa), 
a'cartilaginous  (anchylosis  cartilaginea),  and  a  bony  anchylosis  (anchy- 
losis ossea).  '  The  cicatricial  connective  tissue  which  develops  between 
the  opposed  articular  surfaces  in  the  healing,  for  example,  of  an  arthri- 
tis with  fungous  granulations,  either  takes  the  form  of  adhesions  which 
resemble  ligaments,  or  they  more  or  less  completely  fill  the  joint.  If 
'ossification  of  the  connective  tissue  takes  place  it  is  possible  for  a  bony 
anchylosis  to  occur,  in  which  case  the  articular  ends  of  the  bones  are 
joined  together  by  an  osseous  bridge,  or  united  by  bone  throughout 
their  entire  extent.  Bony  anchylosis  may  develop  from  the  cartilag- 
i_nous  form,  or  it  may  arise  from  the  direct  coalescence  of  joint  sur- 
faces which  have  lost  their  covering  of  cartilage. '  Cartilaginous  anchy- 
losis is  brought  about  by  a  growth  of  vascular  connective  tissue  be- 
tween the  opposed  surfaces  of  the  articular  cartilages,  and  if,  then,  this 
connective  tissue  disappears,  the  surfaces  of  the  cartilage  are  found  to 
have  coalesced  into  a  single  cartilaginous  mass.  Other  causes  of  stiff- 
ness in  joints  are  cicatricial  shrinkage  of  the  capsule  and  ligaments  of 
the  joint,  and  adhesions  between  two  opposed  portions  of  the  synovial 
membrane,  so  that  the  latter  can  no  longer  adapt  itself  to  the  move- 
ments of  the  different  portions  of  the  joint.  Anchylosis  may  also  be 
caused  by  the  growth  of  bone  or  cartilage  in  a  joint,  as  in  arthritis 
deformans,  or  by  the  development  of  bone  in  the  capsule  or  parts  sur- 
rounding the  joint,  which  sometimes  occurs  after  fractures  in  the  neigh- 
bourhood of  or  extending  into  a  joint.  Furthermore,  the  articular  ends 
of  bones  may  be  so  altered  by  changes  such  as  occur  in  caries  and  ar- 
thritis deformans  that  they  do  not  fit  together,  and  so  are  not  capable 
of  performing  their  function  of  gliding  over  each  other  (anchylosis  of 
deformity).  We  learned  in  a  previous  chapter  that  joints  may  become 
fixed  in  a  faulty  position  by  muscular  contractures,  or  by  cicatricial 
processes  in  the  muscles,  tendons,  tendon  sheaths,  bones,  etc. 

It  is  generally  an  easy  matter  to  make  the  diagnosis  of  anchylosis, 
but  in  doubtful  cases  chloroform  anaesthesia  may  be  required  to  deter- 
mine whether  the  anchylosis  is  false  or  true ;  it  is  also  the  best  way  of 
finding  out  how  much  motion,  if  any,  exists. 


^98  INJURIES  AND   DISEASES  OF  JOINTS. 

Treatment  of  Anchylosis. — The  treatment  of  a  stiff  joint  includes 
both  an  attempt  at  restoration  of  its  motion  and  at  overcoming  the  ab- 
normal position  in  which  the  joint  may  have  become  anchylosed  ;  in 
other  words,  one  should  strive  to  place  the  joint  in  such  a  position 
that  the  limb  may  be  more  or  less  useful  to  the  patient.  Only  in  rare 
instances  is  it  possible  to  restore  motion  in  a  joint  which  has  become 
fixed  by  true  anchylosis,  and  then  it  is  generally  accomplished  by  re- 
section. But  we  can  very  often  prevent  an  anchylosis  from  taking 
place  by  employing  proper  treatment  for  the  diseases  and  injuries  of 
the  joints  and  the  parts  which  surround  them,  particularly' by  causing 
wounds  to  heal  aseptically,  and  after  the  subsidence  of  inflammation, 
^by  using  massage  and  active  and  passive  motion.  If  in  the  course  of 
an  injury  or  inflammation  of  a  joint  we  are  unable  to  prevent  an 
anchylosis  from  developing,  we  must  always  place  the  joint  in  that 
position  which  will  render  it  most  useful  for  the  patient — the  knee, 
for  example,  in  extension,  the  ankle  and  elbow  at  a  right  angle,  etc. 
If  the  joint  has  already  become  fixed  in  a  distorted  position,  it  may 
be  possible  to  gradually  overcome  the  latter  by  massage  and  passive 
motion,  by'manual  correction  under  anaesthesia,  by  "permanent  exten- 
sion by  a  weight,  by  the  use  of  frequently  applied  plaster-of-Paris 
dressings  or  splints  which  exert  pressure  or  traction,  or  by  operative 
division  of  the  contracted  periarticular  soft  parts,  especially  the  mus- 
cles, tendons,  and  fascia  (see  Tenotomy,  Myotomy,  page  558),  by  oste- 
otomy of  the  bone  in  the  neighbourhood  of  the  joint,  or  by  resection 
of  the  joint,  combined  possibly  with  the  removal  of  a  wedge  of  bone. 
Osteotomy  is  performed  either  in  the  form  of  simple  division  of  the 
bone  (see  §  2G),  or  division  combined  with  the  removal  of  a  wedge- 
shaped  piece  from  the  continuity  of  the  bone.  Volkmann's  method  of 
performing  linear  or  wedge-shaped  osteotomy  below  the  trochanter  of 
a  hip  which  has  become  anchylosed  has  yielded  excellent  results,  im- 
proving both  the  position  and  the  usefulness  of  this  joint.  Resection 
of  the  joint  (§  40),  and  in  desperate  cases  amputation  or  disarticulation 
(§  3G  and  §  37),  are  also  operations  which  may  have  to  be  resorted  to. 
When  there  is  a  firm  anchylosis  due  to  fibrous,  cartilaginous  or  bony 
union  between  the  articular  ends  of  the  bones,  combined  with  a  dis- 
torted position  of  the  joint,  resection  of  the  latter  is  generally  called 
for,  the  object  being  the  formation  of  a  movable  joint,  or  one  fixed 
in  a  position  which  will  render  use  of  the  limb  possible.  The  opera- 
tion of  arthrodesis  for  obtaining  artificially  anchylosis  of  a  paralytic, 
flail-like  joint  is  described  in  §  40. 

§  119.  Deformities    of    Joints    (Contractures). — The   deformities   of 
joints  which  we  shall  speak  of  here  are  faulty  positions  in  which  joints 


^119.] 


DEFORMITIES   OF  JOINTS. 


699 


m.ij  have  become  more  or  less  fixed,  and  are  sometimes  congenital  and 
sometimes  acquired,  and  when  acquired  are  called  contractures.  In 
discussing  the  subjects  of  inflammation  and  anchylosis  of  joints  we 
learned  how  contractures  might  develop,  and  consequently  we  shall 
confine  ourselves  at  present  merely  to  a  brief  account  of  the  individual 
forms  of  this  affection,  the  reader  being  referred  to  the  Special  Sur- 
gery for  a  more  detailed  description  of  each,  especially  as  regards  the 
treatment. 

The  coiKjenltal  deformities  of  joints  are  mainly  due  to  disturb- 
ances of  development  which  occur  in  the  foetal  stage  of  life.  The  con- 
genital club-foot  (pes  varus.  Fig.  381) — i.  e.,  the  supination-contracture 
of  the  foot — is  an  example  of  this.  The  supination  is  almost  always 
combined  with  plantar  flexion  (pes  equino-varus).  It  might  be  said 
that  a  slight  amount  of  club-foot  is  physiological,  inasmuch  as  every 
ijifant  at  birth  has  some  suggestion  of  it.  \\  Pronounced  club-foot  is, 
briefly  speaking,  a  disturbance  of  development  in  the  astragalo-crural, 
the  calcaneo-astragaloid,  or  the  astragalo-scaphoid  joints,  which  is 
brought  about  principally  by  the  foot  being  kept  in  continuous  supina- 
tion owing  to  lack  of  space  in  the  uterus.  / '  The  bone  which  undergoes 
the  most  pronounced  change  of  form  in  consequence  of  this  continual 
supination  of  the  foot  in  utero  is  the  astragalus,  the  neck  of  which 
becomes  longer  than  it  normally  should  be,  and  somewhat  bent;  in 
other  words,  the 
growth  of  the  astrag- 
alus adapts  itself  to 
the  abnormal  posi- 
tion which  the  foot 
assumes  in  tdero. 
The  rare  cases  of 
congenital  flat  -  foot 
(pes  valgus  or  pla- 
nus, Fig.  385)  and  of 
pes  calcaneo-valgus 
originate  in  a  similar 
manner,  being  due  to 
the  pressure  exerted 
by  the  walls  of  the 
uterus.  By  pes  cal- 
caneo-valgus is  un- 
derstood a  foot  which  is  dorsally  flexed  to  such  an  extent  that  its 
dorsum  comes  nearly  or  quite  in  contact  with  the  leg,  and  is  at  the 
same  time  abducted  (Fig.  388).     Scoliotic  or  kyphotic  curvatures  of 


Fig.  381.— Club-foot  (pes 
varus). 


Fig.  382. — Club-foot  caused  by  a 
conirenital  absence  of  the  entire 

tibia. 


700 


INJURIES   AND   DISEASES   OF   JOINTS. 


the  spinal  column,  or  club-hand  or  club-foot,  may  also  have  their  ori- 
gin in  congenital  defects  occurring  in  the  vertebrae  or  in  the  bones  of 
the  forearm  or  (lower)  leg  (see  Fig.  382). 

The  acquired  deformities  of  joints  are  due  first  of  all  to  disturb- 
ances occurring  during  the  growth  of  articular  surfaces  previously 
normal,  in  children  and  young  subjects.  Thus  deformities  of  the 
joints  develop  in  the  lower  extremities  and  vertebral  column  as  a 
result  of  the  pressure  exerted  by  the  weight  of  the  body.  Their  origin 
is  to  be  ascribed  to  pressure  on  the  joint  surfaces,  which  is  either  too 
protracted  or  too  excessive,  or  unevenly  distrib^ 
uted.  This  class  of  cases  includes  the  lateral 
curvatures  of  the  spinal  column  or  scoliosis  (Fig. 
383),  genu  valgum  (Fig.  384),  and  flat-foot  (pes 
planus  or  pes  valgus,  Fig.  385).  Rhachitic 
bones  are  particularly  apt  to  sufl'er  from  these 
pressure  deformities  ;  the  pressure  causes  a  grad- 
ual change  in  the  shape  of  the  bones,  their 
growth  being  diminished  in  the  parts  where  the 
pressure  is  greatest  and  increased  where  the 
pressure  is  least.  The  diaphyses  or  epiphyses  of 
the  long  hollow  bones,  especially  if  they  are  soft 
(see  Rhachitis),  are  thus  bent  and  curved  by  the 
weight  which  they  have  to  sustain.  This  is  also 
the  explanation  of  the  change  in  the  shape  of  the 
vertebrae  encountered  in  a  case  of  scoliosis  which 
has  existed  for  a  long  time,  and  of  the  curvatures 
of  the  femur  and  tibia  in  the  neighbourhood  of 
the  junction  of  the  epiphysis  with  the  diaphysis  ; 
of  the  obliquity  of  the  condyles  in  genu  valgum 
(Mikulicz) ;  and  of  the  depression  of  the  arch  of 
the  foot  and  change  in  shape  of  the  tarsal  bones 
in  pes  valgus.  Stretching  or  shortening  of  the 
soft  parts,  especially  the  muscles,  fascia,  and  the  ligaments  of  the  joint, 
may  then  develop  secondarily. 

As  a  result  of  primary  disease  of  the  muscles,  or,  more  commonly, 
of  the  nervous  system,  myopathic  and  neuropathic  deformities,  or,  in 
other  words,  true  contractures  of  joints,  are  produced.  Primary  mus- 
cular contractures  used  to  be  thought  very  common,  and  were  wrongly 
looked  upon  as  the  cause  of  scoliosis  and  flat-foot. 

Neuropathic  contractures  are  divided  into  the  spastic  and  the  para- 
lytic. Spastic  contractures  are  the  result  of  diseases  of  the  central 
nervous  system,  and  hence  belong  more  properly  to  the  province  of 


Fio.  383. — Scoliosis. 


§119.1 


DEFORMITIKS   OP  JOINTS. 


roi 


Fig.  384. — Genu  valgmn. 


internal  medicine,  so  that  we  shall  confine  ourselves  here  to  merely  a 
brief  description  of  them  in  so  far  as  they  are  of  surpcal  importance. 
Little  and  Erb  have  recently  made  a  special  study  of  this  form  of  con- 
tracture, and  have  shown  that  it  is 
not   by  any  means  as  rare  as  has 
hitherto  been  supposed.     Little  has 
also  given  a  description  of  a  con- 
genital spastic  paralysis,  of  which 
liupprecht  has  published  some  typ- 
ical cases. 

Spastic  contractures  (Fig.  386) 
are  due  in  the  main  to  a  hyperin- 
nervation  of  the  muscles,  and  are 
either  congenital,  or  acquired  in 
the  course  of  numerous  diseases  of 
the  brain  and  spinal  cord,  such  as 
tumours,  embolism,  localised  infec- 
tious processes,  injuries,  spondylitis 
with  compression  of  the  spinal 
cord,  chronic  meningitis,  hydro- 
cephalus, syphilis  of  the  brain,  mul- 
tiple sclerosis,  and  finally  as  a  result  of  reflex  action  from  simple  irrita- 
tion of  the  brain.  Heusinger  observed  spastic  contractures  of  the  foot 
in  the  form  of  equino-varus  during  an  epidemic  of  ergotism.  The 
congenital  form  of  spastic  contracture  (Erb's  spastic  spinal  paralysis  of 
children)  is,  according  to  Erb,  due  to  pathological  lesions  which  con- 
sist, as  Little  thinks,  of  interpartum  haemorrhages  into  the  brain  and 
spinal  cord,  resulting  in  sclerosis, 
chronic    meningitis,    and    cerebro-       %  | 

medullary  hyperaemia.  \  1 

The    symptoms  of  spastic  con-  \  fi 

fractures    are    very   characteristic.  i  \ 

The  muscles  are  not  paralysed,  but,  1%  i|v 

on  the  contrary,  possess  an  in- 
creased amount  of  innervation.  As 
illustrated  in  Fig.  386,  the  tightly 
contracted  muscles  of  the  lower  ex- 
tremity compel  the  limb  to  assume 
a  position  of  flexion,  adduction,  and  inward  rotation.  The  resistance 
which  the  muscles  offer  to  an  attempt  at  passive  extension  is  usually 
very  considerable.  If,  however,  the  patient  sits  or  lies  down,  placing 
liis  body  completely  at  rest,  and  if  the  points  of  origin  and  insertion 


Fig. 


-Pes  valgus. 


702 


INJURIES   AND   DISEASES   OF  JOINTS. 


of  the  flexor  muscles  are  approximated,  the  muscles  immediately  be- 
come relaxed.  But  every  effort  to  use  the  muscles  actively  or  to 
extend  them  passively,  or  any  application  of  electricity,  straightway 
gives  rise  to  a  tetanic  contraction  which  renders  co-ordinated  move- 
ments impossible.  Under  chloroform  the  muscles  of  young  persons 
become  completely  limp,  and  all  movements  can  be  easily  made ;  but 

the  muscles  and  ligaments  on 
the  flexor  aspects  of  the  limbs 
of  older  patients,  as  illustrated 
in  Fig.  386,  are  ordinarily  so 
shrunken  that  complete  exten- 
sion will  no  longer  be  possible. 
The  paralytic  contractures 
— i.  e.,  those  which  are  the  re- 
sult of  paralytic  conditions  and 
follow  injuries  and  diseases  of 
the  central  nervous  system  and 
peripheral  nerves  —  are  ex- 
tremely common  (see  Figs. 
387,  388,  389).  They  include 
the  paralytic  contractures 
which  occur  so  frequently  with 
the  partial  or  total  paralyses 
following  meningitis  and  en- 
cephalitis in  children,  and  the 
spinal  (so-called  essential)  in- 
fantile paralyses  which  affect 
almost  exclusively  the  lower  extremity.  Of  the  paralytic  contractures 
of  the  foot  the  most  common  are  the  pes  equinus  paralyticus  (Fig.  387) 
and  the  paralytic  club-foot  which  very  often  takes  the  form  of  pes 
equino-varus  jjaralyticus.  In  the  paralytic  club-foot  the  equinus  posi- 
tion predominates,  but  in  the  congenital  form  the  varus  contracture — 
i.  e.,  the  adduction  and  supination — is  the  most  noticeable  feature  (Fig. 
381).  The  pes  calcaneus  paralyticus  (Fig.  388)  and  the  pes  valgus  par- 
alyticus (Fig.  385)  are  much  rarer.  Paralytic  contractures  of  the  knee, 
the  hip,  and  especially  of  the  hand,  where  they  may  follow  injuries  of 
the  ulnar,  median,  or  musculo-spiral  nerves,  are  comparativeh'  com- 
mon. Fig.  389  illustrates  the  typical  main  en  griffe,  or  claw  position, 
assumed  by  the  fingers  after  paralysis  of  the  ulnar  nerve.  In  the  re- 
gion of  the  spinal  column  paralytic  contractures  take  the  form  of  later- 
al curvatures  (paralytic  scoliosis)  or  of  flexion  or  extension  contractures 
(paralytic  kyphosis  and  lordosis).      In  all  cases  paralysis  of  any  one 


Fig,  386. 


-Spastic  contracture  of  the  lower  extrem- 
ities. 


§  119.] 


DEFORMITIES   OF  JOINTS. 


f03 


particular  group  of  muscles,  or  rather  of  the  nerves  which  su])pl y  them, 
invariably  gives  rise  to  a  characteristic  contracture  (.>5ee  Special  tSurgery, 
§2^4). 


Fio.  3S7. — Pes  equinus      Fig.  3" 
paralyticu-s. 


8. — Pes  eak-aneus  paralyt- 
icus. 


Fig.  389.— "CI  aw  position"  (main 
en  griffe)  ot  the  fingers  follow- 
ing paralysis  of  the  vuuar  nerve. 


Infantile  Spinal  Paralysis. — As  the  spinal  paralysis  of  children  often 
leads  to  paralytic  contractures,  it  should  be  briefly  described  at  this 
point.  The  disease  usually  attacks  children  between  one  and  four 
years  of  age.  The  acute  infectious  diseases  and  rheumatism  have  an 
important  etiological  bearing  upon  it,  and  heredity  is  sometimes  to  be 
taken  into  consideration.  Pathologically  it  is  an  acute  inflammatory 
process  situated  in  the  anterior  grey  horns  of  the  spinal  cord  fpolio- 
myelitis  acuta),  and  is  most  commonly  located  in  the  luml^ar,  less  often 
in  the  cervical,  enlargement ;  it  is  either  unilateral  or  bilateral,  and  is 
characterised  by  hyperaemia,  by  haemorrhages,  and  by  red  softening 
with  degeneration  of  the  ganglion  cells  and  nerve  fibres.  This  inflam- 
matory process,  which  at  the  outset  is  acute,  results  in  the  development 
of  a  circumscribed  or  diffuse  sclerosis  (connective-tissue  growth)  with 
secondary  atrophy  of  the  nerve  fibres,  and  a  subsequent  secondary  de- 
scending degeneration  of  the  nerves.  The  muscles  supplied  by  these 
nerves  likewise  undergo  a  degenerative  atrophy,  and  in  addition  be- 
come the  seat  of  a  secondary  interstitial  growth  of  connective  tissue  or 
fat.  The  atrophy  of  the  nerves  and  their  roots  is  a  secondary  change, 
and  that  of  the  muscles  is  a  result  of  the  loss  of  their  trophic  centres  in 
the  anterior  columns  of  grey  matter.  Leyden  states  that  the  affection 
may  also  result  from  a  peripheral  multiple  neuritis,  the  latter  in  part 
remaining  peripheral  and  in  part  leading  to  localised  disease  of  the 
spinal  cord. 


704  INJURIES  AND   DISEASES   OF  JOINTS. 

I  must  refer  the  reader  to  the  text-books  on  nervous  diseases  for  a 
full  description  of  the  symptomatology  of  infantile  spinal  paralysis,  as 
only  the  following  brief  outline  will  be  given  here.  The  disease  usu- 
ally begins  suddenly  without  prodromata,  with  a  high  fever,  40°  to  41° 
C.  (104°  to  105'8°  F.),  and  corresponding  acute  manifestations  accom- 
panied by  stupor,  convulsions,  etc.  Occasionally  this  acute  febrile 
onset  is  absent.  After  one  or  two  days  the  acute  manifestations  gen- 
erally disappear.  The  paralysis  develops  during  the  time  that  the  tem- 
perature is  elevated,  but  is  usually  not  noticed  till  later.  It  spreads  at 
first  very  rapidly,  and  may  affect  all  the  muscles  of  the  limbs  and  even 
those  of  the  trunk.  It  then  ordinarily  diminishes,  leaving  a  perma- 
nent paralysis  which  varies  greatly  in  extent,  but  is  generally  mono- 
plegia and  confined  to  one  leg,  less  often  paraplegic,  and  still  more  in- 
frequently takes  the  form  of  spinal  hemiplegia  or  of  crossed  spinal 
hemiplegia  (leg  and  arm  of  different  sides).  Often  only  parts  of  a 
limb,  or,  more  exactly,  only  certain  groups  of  muscles,  are  affected. 
The  permanent  paralysis  is  purely  motor,  and  is  characterised  by  a 
rapidly  progressing  atrophy  of  the  muscles.  Within  one  or  two  weeks 
the  faradic  excitability  is  lost,  though  at  the  outset  there  is  a  temporary 
increased  response  to  the  galvanic  current,  especially  to  the  positive 
pole.  There  are  to  be  noted,  in  addition  to  the  reaction  of  degenera- 
tion, the  absence  of  the  cutaneous  and  tendon  reflexes  in  the  region 
where  the  muscles  are  paralysed,  the  not  uncommon  hyperalgesia  of 
the  latter  on  pressure,  and  their  steadily  increasing  atrophy,  and,  above 
all,  the  previously  mentioned  contractures  which  most  frequently  occur 
in  the  foot.     The  treatment  is  given  on  page  Y06. 

The  Manner  in  which  Contractures  Develop. — How  do  the  various 
paralytic  coTitractures  which  occur  in  such  typical  forms  come  to  take 
place  ?  Delpech  was  of  the  opinion  that  they  were  produced  by  active 
shortening  of  the  non-paralysed  antagonistic  groups  of  muscles,  and 
that  for  this  reason  the  contracture  took  place  towards  the  side  of  the 
antagonists.  But  Volkmann  and  Hueter  have  shown  that  this  antago- 
nistic theory  is  not  in  itself  sufficient  to  explain  the  manner  in  which 
paralytic  contractures  develop ;  that,  in  fact,  the  contracture  of  the  an- 
tagonists is  quite  commonly  absent,  and  that,  in  addition,  the  contrac- 
ture really  forms  in  the  direction  of  the  paralysed  group.  They  proved 
that  the  weight  of  the  limb,  and,  in  the  case  of  the  lower  extremity,  the 
superimposed  weight  of  the  body,  play  very  important  parts  in  the 
production  of  the  paralytic  contractures.  This  is  the  way  in  which  the 
pes  equinus  paralyticus  (Fig.  387)  develops,  since  the  foot  drops  down 
of  its  own  weight — in  other  words,  assumes  a  position  in  plantar  flex- 
ion, no   matter  whether  all   the  muscles  of  the  Icir  below  the  knee  or 


gll9.]  DKFORMITIKS   OF  JOINTS.  705 

only  the  extensors  are  paralysed.  This  equinus  ])osition  of  the  foot 
may  also  result  from  a  paralysis  which  is  limited  to  the  muscles  of  the 
calf  alone,  for  the  reason  that  the  paralysed  muscles  undergo  a  short- 
ening from  lack  of  nutrition.  The  weight  of  the  paralysed  limb  can 
likewise  be  shown  to  have  an  effect  upon  the  development  of  contrac- 
tures in  other  joints  of  the  upper  and  lower  extremity. 

The  pressure  exerted  upon  the  paralysed  part  by  the  weight  of  the 
body  is  a  matter  of  importance  in  the  production  of  the  various  con- 
tractures which  may  occur  in  the  spinal  column  and  in  the  lower  ex- 
tremity when  the  affected  limb  is  used  for  standing  and  walking.  This 
partially  explains  the  way  in  which  the  paralytic  scoliosis  and  paralytic 
tlat-foot  develop.  The  rare  deformity  known  as  pes  calcaneus  (Fig. 
388),  which  is  usually  combined  with  a  valgus  position — i.  e.,  a  drop- 
ping of  the  inner  border  of  the  foot— is,  according  to  Volkmann,  caused 
by  a  tipping  forward  of  the  os  calcis,  due  to  the  latter  not  being  held 
firmly  enough  in  position  by  the  muscles  of  the  calf. 

The  diagnosis  of  paralytic  contractures  is  usually  easy,  and  can  be 
made  from  their  general  appearance,  without  an  electrical  examination 
(see  Injuries  of  Nerves,  Diseases  of  Nerves,  §  87,  §  88,  and  §  97). 

The  pnre  myopathic  contractures  due  to  primary  disease  of  nmscles 
are  much  rarer  than  the  neuropathic,  and  result  from  certain  forms  of 
atrophy,  injury,  and  inflannnation  of  muscle  (see  §  98). 

The  cicatricial  contractures,  especially  those  due  to  loss  of  substance 
in  the  skin  and  subcutaneous  soft  parts  following  acute  and  chronic 
inflammations  of  the  soft  parts  and  joints,  have  already  been  sufficiently 
described  in  the  chapters  on  Healing  of  Wounds  (§  01)  and  on  injuries 
and  Inflammations  of  the  Soft  Parts  (§§  87-100). 

We  have  thus  gained  an  understanding  of  the  numerous  causes 
which  give  rise  to  contractures,  and  can  now  distinguish  two  main 
groups  of  those  which  involve  joints,  basing  the  classification  upon  the 
manner  in  which  they  originate.  Tliese  are,  (1)  arihrogenic  contrac- 
tures resulting  from  congenital  or  acquired  changes  in  the  parts  which 
constitute  the  joint,  and  (2)  non-arthrogenic  contractures  due  to  patho- 
logical changes  in  the  neighbourhood  of  the  joint,  or  to  other  diseases, 
especially  those  of  the  nervous  system.  The  neurogenic,  myogenic, 
and  tendogenic  contractures  which  follow  diseases  or  injuries  of  the 
nerves,  muscles,  or  tendons,  or  are  brought  about  by  shrinkage  of 
fascia,  etc.,  belong  to  the  non-arthrogenic  class.  The  cicatricial  con- 
tractures which  follow  losses  of  substance  from  traumatism  or  inflam- 
mation, or  are  the  result  of  adhesions,  may  occur  in  any  part  of  the 
body.     Contractures  of  joints  are  sometimes  produced  by  causes  which 

are  partly  arthrogenic  and  partly  non-arthrogenic,  as,  for  example,  in 
■45 


706 


INJURIES   AND   DISEASES  OF  JOINTS, 


cLronic  inflammations  of  the  hip  (coxitis),  where  tliere  develops  along 
with  the  inflammation  a  progressive  shrinkage  of  the  fascia  lata,  unless 
this  is  prevented  by  proper  treatment  (Fig.  390).     Muscular  contrac- 


Fio.  390.— Contracture  of  tlie  hip-joint  in  coxitis  from  shrinka^fc  of  the  fascia  lata. 

tures  in  diseases  of  joints  are  also  very  frequently  caused  by  reflex 
action,  as  described  on  pages  549  and  554. 

Treatment  of  Deformities  and  Contractures  of  Joints. — The  treatment 
of  very  many  of  the  deformities  and  contractures  of  joints  belongs 
really  to  the  province  of  orthopaedic  surgery,  which  has  made  great 
progress  in  the  last  few  years.  It  would  require  too  much  space  to 
describe  at  length  the  treatment  of  each  separate  deformity,  but  it  will 
suffice  to  say  here  that  in  general  the  treatment  consists  in  the  use  of 
immobilising  dressings  (plaster  of  Paris,  extension),  supporting  appara- 
tus, operative  measures  (osteotomy,  tenotomy,  myotomy),  electricity, 
massacre,  and  gymnastics.  The  treatment  of  cicatricial  contractures 
which  have  resulted  from  inflammation  and  injury  of  the  soft  parts 
has  already  been  spoken  of  in  connection  with  Injuries  and  Inflannna- 
tions  of  the  Soft  Parts  (§§  8Y-100),  and  the  treatment  of  arthrogenic 
contractures  has  been  given  in  connection  with  inflammations  and 
anchylosis  of  joints  (§§  113-118). 

The  treatment  of  infantile  spinal  paralj'.sis  consists  in  the  use  of 
massage,  electricity,  and  a  strengthening  mode  of  life.  A  weak  con- 
stant current  should  be  applied  to  the  spinal  cord  as  early  as  possible, 
by  placing  one  of  the  large,  flat  electrodes  over  the  portion  which  is 
supposed  to  be  the  seat  of  the  disease,  and  the  other  electrode  on  the 
anterior  surface  of  the  trunk,  and  then  alternating  the  action  of  the 
anode  with  that  of  the  cathode.  In  addition,  the  muscles  themselves 
are  treated  with  weak  faradic  or  constant  currents,  and  massaged,  or 
rubbed  witli   alcohol.     Baths  (hot   baths,  salt  l)aths,  sea  baths,  etc:)  are 


§  120.]  INJURIES   OF  JOINTS.  7O7 

useful,  as  well  as  other  hydrotherapeutic  measures ;  also  the  internal 
administration  of  the  iodide  of  potassium,  nitrate  of  silver,  ergotine, 
iron,  strychnine,  cod-liver  oil,  and  linally  good  air  and  nourishing  food. 
Supporting  apparatus  or  immobilising  dressings  should  be  used  to  pre- 
vent the  occurrence  of  deformities,  especially  in  the  lower  extremities. 

The  congenital  spastic  contractures  are  treated  at  lirst  by  passive 
movements  of  the  joints,  and  later  by  lukewarm  baths,  galvanisation  of 
the  spinal  cord,  and  irritation  of  the  skin  along  the  spinal  column.  In 
order  to  prevent  or  correct  deformities,  it  is  a  good  plan  to  use  plaster- 
of-Paris  dressings  or  suitable  orthopai'dic  contrivances.  Tenotomy  is 
often  of  great  value;  it  not  only  corrects  deformity,  but  acts  directlv 
as  an  antispasmodic  measure. 

§  120,  Injuries  of  Joints.— Injuries  of  joints  aie  divisible  into  two 
main  groups,  (1)  subcutaneous  and  (2)  open.  The  latter  are  also  called 
penetrating,  as  they  enter  the  joint  cavity.  AVe  shall  first  take  up  con- 
tusions of  joints. 

Joint  Contusions. — Contusions  resulting  from  a  blow  with  some 
blunt  instrument,  or  from  a  fall,  are  the  mildest  form  of  injury  to  a 
joint.  The  contusions  may  be  direct  or  indirect,  depending  upon 
whether  the  violence  which  causes  the  injury  acts  directly  upon  the 
joint,  or  indirectly  by  contre  eoup.  Indirect  contusions  of  the  hip,  for 
example,  are  caused  by  a  fall  upon  the  feet  or  upon  the  trochanter.  In 
indirect  contusions  the  principal  injury  is  a  greater  or  less  amount  of 
crushino;  of  the  articular  surfaces  brouijht  about  bv  the  latter  beinor 
forced  against  one  another,  and  in  the  worst  cases  a  fracture  may  occur 
with  impactioi^  of  the  fragments  ;  but  in  direct  contusions  it  is  mainly 
the  surrounding  soft  parts  and  the  synovial  membrane  which  are 
injured. 

The  most  important  symptom  of  a  contusion  of  a  joint  is  the  ef- 
fusion of  blood  into  the  latter — the  hsemarthros — which  is  in  some  cases 
slight,  in  others  very  marked,  so  that  the  joint  feels  tense.  If  the  joint 
is  tilled  to  its  utmost  limits  it  becomes  slightly  flexed,  as  this  jjosition 
renders  it  most  relaxed  and  gives  it  its  greatest  capacity.  The  effusion 
of  blood  is,  of  course,  most  easily  made  out  in  joints  like  the  knee, 
which  are  superficially  situated.  In  haemophilia  and  scurvy  an  effusion 
sometimes  occurs  spontaneously,  or  as  a  result  of  very  slight  injuries. 
Other  symptoms  of  joint  contusions  are  an  infiltration  of  the  skin  and 
the  subcutaneous  soft  parts  with  blood,  especially  if  the  contusion  is 
direct ;  pain  in  the  joint,  which  is  usually  slight,  and  made  worse  by 
movement;  and  disturbance  of  function,  varying  with  the  amount  of 
blood  which  is  effused.  For  the  symptoms  caused  by  a  fracture  of  the 
bony  parts  of  a  joint  the  reader  is  referred  to  §  101  (Fractures). 


/^Qg  INJURIES   AND   DISEASES   OF  JOINTS. 

The  subsequent  course  of  a  contusion  of  a  joint  which  is  not  com- 
plicated by  a  fracture  is,  as  a  rule,  favourable,  and  complete  recovery 
usually  follows  in  a  short  time,  though  occasionally  slight  inflammatory 
symptoms,  or  hydarthros,  persist  for  a  good  while.  It  is  only  in  very 
exceptional  instances  that  suppuration  takes  place  wntliin  the  joint, 
from  a  suppurative  process  which  originates  in  a  laceration  of  the  skin, 
gradually  extends  to  the  deeper  parts  and  finally  involves  the  articula- 
tion. Suppuration  of  the  effusion  of  blood,  due  to  micro-organisms 
which  are  deposited  by  the  circulating  blood,  is  extremely  rare,  but 
in  a  tubercular  or  scrofulous  person  a  tubercular  inflammation  not  in- 
frequently results  from  a  contusion  or  sprain  of  a  joint. 

The  diagnosis  of  contusion  can  usually  be  easily  made  from  the 
swelling  of  the  joint  coming  on  after  a  traumatism,  from  the  fluctua- 
tion, the  pain  on  movement,  and  the  more  or  less  marked  loss  of  func- 
tion. The  eiiusion,  if  sufficient  in  amount,  assumes  the  outward  con- 
figuration of  the  joint.  The  possibility  of  haemophilia,  as  well  as  of 
fracture,  should  always  be  thought  of,  and  as  careful  an  examination  as 
possible  made  with  these  in  view. 

The  treatment  of  joint  contusions  consists  in  the  employment  of 
massage  at  an  early  period,  in  order  to  get  rid  of  the  effusion  by  press- 
ing it  into  the  interstices  between  the  tissues  and  bv  causing  it  to  be 
al)sorbed  by  the  lymphatics.  Pressure  applied  to  the  joint  by  means  of 
elastic  bandages,  and,  above  all,  repeated  movements  of  the  joint,  also- 
promote  the  resorption  of  the  blood.  In  this  way  joint  contusions  are 
made  to  get  well  very  rapidly,  and  even  very  large  effusions  will  dis- 
appear in  a  few  days  if  massage  is  begun  as  soon  as  possible  after  the 
accident.  Contusions  of  joints  used  to  be  treated  by  keeping  the  joint 
at  rest  and  l)y  applying  ice.  Ice  is  seldom  necessary,  and  then  only  in 
the  first  stages,  to  soothe  the  pain  ;  but  keeping  the  joint  at  rest  is  ac- 
tually harmful  in  typical  cases  uncomplicated  by  a  fracture,  as  the  or- 
ganisation of  the  effusion  into  connective  tissue  is  thus  materially 
helped.  Puncture  and  antiseptic  irrigation  of  the  joint  (see  page  665) 
are  only  necessary  when  the  joint  is  distended  to  its  utmost  capacity. 
For  the  treatment  of  a  hydarthros  or  suppuration  of  a  joint  which 
may  follow  a  contusion,  the  reader  is  referred  to  ^§  113,  114.  A  sub- 
cutaneous fracture  within  a  joint  is  treated  according  to  the  rules  laid 
down  on  page  596. 

§  121.  Sprains  (Distortions). — By  a  sprain  or  distortion  we  mean  a 
momentary,  forcible  stretching  and  twisting  of  a  joint,  usually  combined 
with  a  laceration  of  certain  portions  of  its  capsule  and  ligaments.  At 
present  we  shall  omit  all  mention  of  the  severe,  complicated  lacerations 
which  are  accompanied  by  opening  of  the  interior  of  the  joint,  as  we 


t?  121.]  SPRAINS.  709 

shall  return  to  these  injuries  under  the  subject  of  Penetrating  Wounds 
of  Joints,  and  shall  confine  ourselves  here  simply  to  a  description  of 
the  typical  subcutaneous  sprains  or  distortions  which  occur  with  such 
great  frequency. 

Besides  the  stretching  and  tearing  of  the  capsule  and  ligaments  of 
the  joint  and  the  ])eriarticular  soft  parts  which  we  have  just  men- 
tioned, there  also  occurs  a  temporary  change  in  the  normal  position  of 
the  articular  ends  of  the  bones — a  momentary  partial  dishx-ation,  as  it 
were — but  as  soon  as  the  force  has  ceased  to  act  they  return  to  their 
])roper  position.  Sprains  are  usnall}'  caused  by  the  same  sort  of  vio- 
lence as  dislocations  (see  §  122)— i.  e.,  by  forced  movements  which 
are  carried  beyond  the  physiological  limits,  or  which  are  at  variance 
with  the  normal  mechanism  of  the  joint.  The  amount  of  force  ap- 
plied in  causing  sprains  is,  however,  not  sufficient  to  bring  about  a 
more  than  temporary  separation  of  the  articular  ends  of  the  bones,  and 
only  a  stretching  or  partial  tearing  of  the  capsule  and  ligaments  takes 
place,  though  in  the  severest  cases  these  structures  may  be  completely 
ruptured.  Sprains  of  the  wrist  are  usually  the  result  of  hyperexten- 
sion,  hyperflexion,  or  torsion  of  the  hand,  and  those  of  the  ankle  of 
forced  pronation  or  supination  of  the  foot.  Simultaneously  with 
sprains  of  the  joint  the  neighbouring  muscles  and  tendons  are  of 
course  often  stretched  and  lacerated,  but  a  partial  or  complete  rup- 
ture of  the  muscles  and  tendons  or  dislocation  of  the  latter  is  only 
observed  in  rare  instances.  Injuj'ies  of  bones,  consisting  in  contusions 
of  their  articular  ends,  or  in  tearing  or  chipping  off  portions  of  them, 
are  common  occurrences  in  distortions.  Examples  of  such  injuries  are 
fractures  of  the  fibula  or  internal  malleolus  in  sprains  of  the  ankle, 
fractures  of  the  lower  end  of  the  radius  in  sprains  of  the  wrist,  and 
cortical  tear-fractures  {Riss-fracturen) — i.  e.,  the  tearing  away  of  pieces 
of  bone  which  form  the  })oints  of  insertion  of  ligaments  and  tendons. 
I  should  not  omit  mentioning  the  dislocations  of  interarticular  carti- 
lages which  may  take  place — the  semilunar  fibro-cartilages  of  the  knee, 
for  example — in  sprains  of  the  latter  joint. 

The  symptoms  of  a  sprain  consist  mostly  in  a  very  intense  pain,  in 
consequence  of  which  the  active  function  of  the  joint  is  disturbed,  the 
joint  becoming  completely  powerless  and  as  though  paralysed.  There 
is  usually  a  diffuse  swelling  of  the  joint,  caused  by  the  intra-articular 
and  periarticular  effusion  of  blood,  and  if  a  fracture  is  present  at  the 
same  time  this  effusion  is  very  marked.  Later,  owing  to  changes  in 
the  colouring  matter  of  the  blood  situated  in  the  skin  and  subcutaneous 
tissue,  bluish-red,  bluish-green,  dark  yellow  or  yellow  discolourations 
make  their  appearance.     The  subsequent  course  of  sprains  in  typical 


710  INJURIES  AND  DISEASES  OF  JOINTS. 

cases  is  usually  favourable,  and  as  a  rule,  if  proper  treatment  is  adopted, 
they  get  well  very  rapidly.  In  cases  complicated  with  a  fracture,  the 
final  outcome,  especially  as  regards  restoration  of  the  function  of 
the  joint,  is  dependent  upon  the  nature  and  location  of  the  break  in 
the  bone.  Complicated  cases  of  sprain  may  occasionally  give  rise  to 
chronic  deforming  inflammations  of  the  joint,  which  obstinately  resist 
every  form  of  treatment.  In  other  instances  anchylosis  may  develop, 
or  the  opposite  conditions  may  be  encountered,  the  articulation  becom- 

-  ino-  loose  and  flail-like  from  the  stretching  and  displacement  of  its 
various  constituents,  so  that  subluxations,  or  partial  dislocations  of 
joints,  like  the  wrist,  knee  (genu  valgum),  or  ankle  (flat-foot),  may 
result.  The  consequences  which  may  ensue  from  an  unrecognised 
rupture  of  a  tendon  or  separation  of  the  latter  from  its  point  of  attach- 
ment are  also  worthy  of  consideration.  Sprains,  like  contusions,  are 
only  followed  by  acute  suppuration  of  the  joint  in  very  exceptional 
instances;  but  not  infrequently  predisposed  individuals  may  subse- 
quently acquire  a  tubercular  arthritis  in  a  joint  wdiicli  has  been  the 
seat  of  a  distortion. 

The  diagnosis  of  sprains  can  be  easily  made  from  what  has  been 
said;  but  the  joint  should  always  be  carefully  examined  for  fracture, 
especially  when  the  injury  is  near  the  hand  or  foot. 

The  treatment  of  subcutaneous  sprains  which  are  not  complicated  by 
a  fracture  is  essentially  the  same  as  that  of  a  contusion  of  a  joint,  and 
consists  in  early  massage,  intermittent  bandaging  of  the  joint  with  an 
elastic  bandage,  and  the  use  of  methodical  movements.  Antiplilogesis 
is  very  frequently  not  necessary,  or  at  most  only  in  the  first  few  hours 
or  days.  Massage,  in  cases  not  complicated  by  a  fracture,  frequently 
seems  to  act  in  a  marvellous  way,  and  a  joint  which  is  still  perfectly 
stiff  and  without  function  may  again  be  made  capable  of  active  mo- 
tion and  of  performing  all  its  functions  by  massaging  it  only  once. 
The  sooner  massage  is  begun  the  better.  Rest  and  immobilisation  in 
uncomplicated  cases  are  to  be  condemned.  If  a  fracture  is  present, 
it  should  of  course  be  treated  according  to  the  .general  principles  which 
apply  to  it.  In  the  rare  cases  of  complete  rupture  of  the  tendons  or 
capsule,  the  joint  must  likewise  at  first  be  immobilised  until  the  tears 
in  these  structures  have  united.  If  tendons  have  been  ruptured,  their 
ends  may  ultimately  have  to  be  joined  together  by  catgut  sutures. 
Other  complications,  such  as  suppurative  arthritis — which  very  rarely 
occurs — are  to  be  treated  in  the  usual  way.  Puncture  and  antiseptic 
irrigation  of  the  joint,  on  account  of  extreme  distention  of  the  latter 
with  blood,  are  called  for  only  in  exceptional  instances. 

),  ;'  §  122.  Dislocations  (Luxations)  of  Joints. — By  a  dislocation  is  meant 


§1-22.]  DISLOCATIONS  OF  JOINTS.  711 

a  permanent  displacciuent  of  tlie  artieular  ends  of  two  or  more  of  the 
bones  making  up  the  joint.  Dislocations^are  complete  or  incomplete,  the 
latter  also  being  called  subluxations.  In  complete  dislocations  the  op- 
posed joint  surfaces  are  entirely  separated  from  one  another,  while  in 
the  incomplete  variety  the  articular  ends  are  still  in  contact,  having 
merely  changed  their  relative  positions  in  regard  to  each  other.  The 
dislocations  of  amphiarthroses  like  the  symphysis  pubis  are  usually 
called  diastases.  A  distinction  is  also  made  between  recent  and  old, 
and  between  simple  and  complicated  or  compound  dislocations.  The 
latter  include  those  especially  which  are  associated  with  open  wounds  in 
the  soft  parts,  with  ruptures  of  large  vessels  or  nerves,  or  with  fractures. 

As  regards  the  causation  of  dislocations,  we  distinguish  (1)  the  trau- 
matic, due  to  external  violence,  (2)  the  spontaneous,  pathological,  or 
inriammatory  dislocations  which  occur  in  the  course  of  an  inflamma- 
tion in  a  joint,  and  (3)  the  congenital  dislocations. 

I.  Traumatic  Dislocations. — Traumatic  dislocations  are  almost  al- 
ways the  result  of  external  violence,  rarely  of  excessive  muscular  ac- 
tion. The  force  is  usually  applied  indirectly,  so  that  the  bones  are 
separated  from  one  another  by  leverage,  the  power  being  exerted  at  a 
greater  or  less  distance  from  the  joint.  Thus,  as  a  rule,  forced  move- 
ments are  caused  to  take  place  which'  go  beyond  the  physiological 
limits  of  flexion,  extension,  abduction,  adduction,  pronation,  or  supi- 
nation, or^movements  are  produced  which  are  at  variance  with  the 
normal  mechanism  of  the  joint,  particularly  forced  rotation.  In  every 
joint  there  exists  a  mechanism  for  checking  its  motion ;  this  is  gener- 
ally made  up  of  bone,  less  often  of  the  ligaments  or  capsule  of  the 
articulation.  When  a  dislocation  takes  place  this  natural  inhibitory 
mechanism  is  overcome,  and  the  articular  end  of  the  bone  is  pressed 
against  this  check  to  its  further  movement,  which  then  becomes  the 
fulcrum.  If  the  force  ceases  to  act  at  this  stage,  the  articular  ends  of 
the  bones  return  to  their  normal  position  of  contact  with  one  another, 
and  only  a  sprain  is  the  result ;  but  if  the  force  keeps  on  acting,  one 
of  til e  articular  surfaces  is  lifted  from  the  other,  the  capsule  ruptures, 
the  ligaments  and  muscular  insertions  which  resist  are  stretched  or 
likewise  ruptured,  and  the  articular  end  of  the  bone  escapes  either 
partially  or  completely  from  the  capsule. 

In  a  dislocation  of  the  elbow  from  over-extension,  the  olecranon 
fossa  acts  as  the  fulcrum  against  which  presses  the  tip  of  the  olec- 
ranon process.  At  the  hip  the  rim  of  the  acetabulum  is  the  fulcrum. 
The  point  where  the  displaced  articular  end  of  the  bone  finally  comes 
to  rest  depends  upon  the  nature  of  the  movement  and  the  amount  of 
iorce  brought  to  bear.     After  the  force  which  produces  the  injury  has 


712  INJURIES   AND   DISEASES   OF  JOINTS. 

ceased  to  act,  the  dislocated  articular  end  of  the  bone  is  made  to  as- 
sume some  particular  position  by  a  so-called  (secondary  inovement, 
brought  about  bj  the  elasticity  of  the  soft  parts — skin,  ligaments,  cap- 
sule, and  muscles.  In  this  the  weight  of  the  limb  and  the  movements 
made  by  the  injured  person  or  by  others  are  also  to  be  taken  into  con- 
sideration. The  dislocated  articular  end  of  the  bone  is  held  in  its  new 
position  mainly  by  means  of  the  uninjured  portions  of  the  capsule  and 
accessory  ligaments.  The  dislocations  caused  by  direct  violence,  such 
as  a  blow  or  fall  upon  the  joint,  are  much  rarer. 

^  Occasionally  dislocations  result  from  inuscular  action,  especially  at 

the  shoulder  (Cooper,  Streubel,  etc.),  where  they  have  been  caused  by 
making  attempts  to  seize  an  object  placed  above  the  head,  or  by  pull- 
ing with  the  hand  elevated.  The  dislocations  of  the  lower  jaw  due  to 
opening  the  mouth  too  wide,  as  in  yawning,  are  also  produced  by  mus- 
cular action  ;  and  dislocations  following  general  muscular  contractions, 
as  in  epilepsy  or  eclampsia,  belong  to  the  same  category. 

Many  persons  can  dislocate  their  joints  voluntarily  ;  but  these  dis- 
locations— that  of  the  first  phalanx  of  the  thumb  being  a  common  ex- 
ample— are  not  ordinarily  complete,  though  in  some  instances  they 
may  be.  The  well-known  athlete  Warren  was  able  at  will  to  com- 
pletely dislocate  most  of  his  joints,  including  the  shoulder  and  hip, 
and,  in  the  case  of  the  latter,  to  cause  the  head  of  the  femur  to  lie 
two  inches  above  ISTelaton's  line.  Then,  when  he  wished,  he  could  re- 
duce it  again,  causing  a  loud,  snapping  sound.     Acrobats  and  so-called 

r*>^'^7i' snake  men  "  bring  about  by  constant  practice  such  a  lengthening  and 
loosening  of  the  capsule  and  ligaments  of  their  joints  that  they  can 
finally  dislocate  the  latter  and  bring  them  back  into  place  again  volun- 
tarily. 

Occurrence  of  Traumatic  Dislocations.— Dislocations  are  most  common  in 
middle  life,  but  are  very  rare  in  old  people  and  young  children,  for  the  reason 
that  external  violence  is  more  likely  to  cause  their  bones  to  break.  Young 
children  are  very  apt  to  sustain  separations  of  the  epiphyses  owing  to  the 
slight  powers  of  resistance  which  the  latter  possess.  Dislocations  of  the 
upper  extremity  are  the  most  common,  amounting,  according  to  Kronlein, 
to  92'3  per  cent,  of  all  luxations,  while  dislocations  of  the  lower  extremity 
amount  to  only  5  per  cent.,  and  those  of  the  trunk  to  only  2 "8  per  cent.  Dis- 
location of  the  shoulder,  on  account  of  the  freedom  of  motion  in  this  joint, 
are  the  most  common,  constituting  about  one  half  of  all  the  dislocations 
which  are  encountered  (51  7  per  cent  ,  Kronlein).  Dislocations  occur  from 
tliree  to  five  times  more  frequently  in  men  than  in  women,  because  the  for- 
mer are  more  exposed  to  injuries  on  account  of  their  occupations.  Disloca- 
tions of  the  lower  jaw  are,  however,  according  to  Kronlein,  about  four  times 
more  common  in  women  than  they  are  in  men. 


g  122.] 


DISLOCATIONS  OP  JOINTS. 


713 


The  anatomical  changes — i.  e.,  the  amount  of  injury  to  the  tissues — 
depend  in  general  upon  the  nature  and  intensity  of  the  force  which  is 
hrought  to  bear  and  the  anatomical  structure  of  the  joint  in  question. 
As  a  rule,  however,  the  following  injuries  to  the  tissues  are  more  or 
less  constant :  The  rent  in  the  capsule,  which  is  always  present  in  a 
complete  traumatic  dislocation,  is  sometimes  slit-shaped  and  sometimes 
irregular  in  form  ;  not  infre<piently  the  capsule  is  torn  from  its  inser- 
tion, and  may  or  may  not  carry  with  it  at  the  same  time  a  portion  of 
the  bone  to  which  it  is  attached.  The  accessory  ligaments  are  either 
stretched,  lacerated,  completely  ruptured,  or  torn  from  their  point 
of  insertion  on  the  bone.  Similar 
ciianges  take  place  in  the  muscles. 
The  intra-articular  and  periarticu- 
lar effusion  of  blood  is  usually  not 
ver}'  large,  and  when  it  is,  a  frac- 
ture may  be  suspected.  The  most 
important  complications  of  trau- 
matic dislocations  are  extensive  in- 
jury to  the  skin  and  subcutaneous 
so^t  parts,  '\he  simultaneous  pres- 
ence of  a  fracture,  and  injuries  to 
large  vessels,  nerves,  and  internal 
organs. 

In  the  majority  of  cases  of  un- 
complicated dislocations,  after  re- 
duction of  the  displaced  articular 
surfaces  has  been  accomplished,  a 
complete  restitutio  ad  i7iteg7'um 
usually  follows,  the  rent  in  the 
capsule  appearing  to  heal  with  es- 
pecial rapidity.  But  if  the  dislo- 
cated articular  end  of  the  bone  re- 
mains in  its  abnormal  position  a 
new  more  or  less  perfect  joint  is  formed — a  so-called  nearthrosis  (see 
Figs.  391,  380).  These  nearthroses  are  sometimes  very  perfectly  de- 
veloped, especially  at  the  hip  and  shonlder.  As  ilhistrated  in  Fig.  391, 
a  new  socket  is  formed  at  the  hip  by  growth  of  the  periosteum,  which 
becomes  covered  with  hyaline  or  fibrous  cartilage.  The  capsule  is  con- 
structed by  an  inflammatory  new  formation  of  tissue  in  the  surround- 
ing soft  parts,  and  its  inner  surface  is  gradually  made  smooth  by  the 
movements  of  the  head  of  the  bone,  so  that  it  may  finally  come  to  re- 
semble a  synovial  membrane.     The  dislocated  end  of  the  bone  usually 


Fig.  391. — Luxatio  femoris  supracotyloidca  in- 
veterata  with  a  very  pert't^etly  formed  new 
acetabulum  (prei>aration  from  the  collec- 
tion in  the  surgical  clinic  at  Bonn — KrOn- 

lein). 


714 


INJURIES  AND   DISEASES  OF  JOINTS. 


atrophies  somewhat,  and  clianges  take  place  in  its  articuhir  surface  cor- 
responding to  the  new  conditions  of  friction  ;  these  changes  are  some- 
times simihir  to  those  of  arthritis  deformans. 

Symptoms  and  Diagnosis  of  Uncomplicated  Traumatic  Dislocations. — 
The  symptoms  of  traumatic  dislocations  are  partly  objective  and  partly 
subjective.  The  objective  symptoms  are  :  (1)  A  change  in  the  contour 
of  the  joint ;  (2)  a  cliange  in  the  relative  positions  of  the  articular  ends 
of  the  bones ;  (3)  a  change  in  the  axis  of  the  bone  or  limb  thouglit  to 
be  dislocated  ;  (4)  a  lengthening  or  shortening  of  the  dislocated  limb 
(Figs.  392,    393).     The  change   in  the  contour  of  the  joint  is  often 

evident  to  an  experienced  eye  at  the 
first  glance.  The  patient  should 
always  be  sufficiently  undressed  to 
render  a  comparison  between  the 
sound  and  damaged  side  possible  ; 
one  can  then  note  the  normal  con- 
figuration of  the  uninjured  joint, 
the  normal  position  of  the  bony 
prominences,  the  relationship  of  the 
folds  of  the  skin  and  soft  parts  on 
the  healthy  and  the  abnormal  de- 
pressions and  elevations  on  the  dis- 
eased side  resulting  from  the 
changed  situation  of  the  head  of 
the  dislocated  bone.  The  most  im- 
portant symptom — viz.,  the  abnor- 
mal position  of  the  head  of  the 
dislocated  bone — can  be  recognised 
by  palpation  or  by  making  move- 
ments with  the  dislocated  limb. 
The  altered  direction  in  which  the  latter  points  is  usually  such  that  the 
long  axis  of  the  luxated  bone  does  not  strike  the  articular  cavity  of  the 
other,  but  passes  outside  of  it ;  in  the  case  of  the  shoulder,  for  exam- 
ple, the  long  axis  of  the  humerus  passes  outside  of  the  glenoid  cavity 
(Figs.  302,  393).  The  dislocated  limb,  in  the  majority  of  instances,  is 
shortened,  rarely  lengthened,  and  assumes  a  position  which  is  perfectly 
characteristic  in  every  dislocation. 

The  subjective  symptoms  are  pain,  and  inability  to  perform  normal 
movements  with  the  injured  limb.  The  disturbances  of  function  usu- 
ally consist  of  a  loss  of  active  motion,  while  passive  movements  are 
possil>le  to  some  extent.  The  latter  are  often  very  easily  carried  out  in 
a  certain  direction,  while  in  others  they  may  be  quite  impossible. 


Fig.  392. — Luxatio  humeri  subcoracoidea 
sinistra. 


§  123.] 


DISLOCATIONS  OF  JOINTS. 


715 


From  wluit  we  huvc  just  said,  it  follows  tliat  tlie  diagnosis  of  dislo- 
cations, especially  soon  after  the  accident,  is  nsually  not  difficult.  If 
tlie  swelling  due  to  the  elfusion  of  blood  is  very 
large,  it  can  be  reduced  in  size  by  gentle  mas- 
sage, possibly  under  an  anresthetic.  Disloca- 
tions are  most  likely  to  be  confused  with  frac- 
tnres  of  the  articular  ends  of  the  bones.  The 
latter  may  be  suspected  if  the  dislocation,  or, 
rather,  the  deformity,  is  easily  reduced  by  slight 
traction  ap})lied  to  the  injured  limb,  but  returns 
again  immediately  when  extension  is  discon- 
tinued. In  dislocations,  on  the  other  hand,  spe- 
cial manoeuvres  are  necessary  to  cause  a  disap- 
pearance of  the  deformity,  and  when  reduction 
has  once  taken  place  the  change  of  contour  does 
iiot  again  recur  spontaneously.  In  fractures, 
abnormal  mobility  and  crepitus  are  usually  pres- 
ent, while  in  dislocations  there  is  an  abnormal 
fixation  of  the  limb,  and  certain  movements  are 
quite  impossible.  A  kind  of  crepitus  is  also 
some  times  met  with  in  dislocations,  but  it  is 
softer  than  bone  crepitus,  and  is  due  to  blood 
coagula  and  to  the  tearing  of  the  ligaments  of 
the  capsule  or  of  the  tendons. 

Complications  of  Dislocations. — The  most  im- 
portant complications  of  dislocations  are  :  (1) 
Extensive  injury  to  the  skin  and  subcutaneous 
soft  parts  over  the  joint ;  (2)  fracture  occurring 
simultaneously  with  the  dislocation ;  (3)  rupture  of  large  vessels  and 
nerves ;  (4)  injury  to  internal  organs. 

''/''  Division  of  the  skin  and  subcutaneous  soft  parts  with  exposure  of 
the  head  of  the  dislocated  bone  is  not  common  ;  it  is  observed  most 
often  at  the  elbow,  in  the  fingei's,  at  the  knee,  and  at  the  ankle.  Such 
compound  dislocations  are  always^to  be  looked  upon  as  serious  injuries, 
especially  when  they  are  combined  at  the  same  time  with  fracture.  The 
sooner  a  compound  dislocation  is  subjected  to  antiseptic  treatment  the 
better  will  be  the  prospect  of  preventing  infection  and  a  serious  suppu- 
rative arthritis  (see  §  123,  AVounds  of  Joints). 

(:2'  The  most  common  complication  of  a  dislocation  is  a  fracture  occur- 
ring at  the  same  time.  The  fracture  may  either  involve  the  cortex,  a 
portion  of  bone  being  torn  off  at  the  point  of  attachment  of  some  liga- 
ment or  tendon,  or  the  fulcrum,  or  the  dislocated  bone  itself,  or''the 


Fig.  393.— Dislocation  of  the 
hip  backwards  (lu.xatio 
iliaca). 


716 


INJURIES   AND   DISEASES  OF  JOINTS. 


non-dislocated  parallel  bone,  such  as  the  ulna,  which  may  be  broken 
below  the  elbow  in  forward  dislocations  of  the  head  of  the  i-adius.  The 
fractures  of  least  importance  are  those  of  the  cortex  and  of  bony  promi- 
nences like  the  tuberosities  of  the  humerus  or  the  malleoli.  Fractures 
of  the  rim  of  the  acetabulum  at  the  hip,  and  of  the  glenoid  cavity  at  the 
shoulder,  are,  on  the  other  hand,  more  serious,  sitice  they  increase  the 
difficulty  of  reduction  or  favour  a  recurrence  of  the  dislocation.  If  a 
fracture  occurs  in  a  dislocated  bone,  the  dislocation  usually  takes  place 
Ijrst  and  then  the  fracture. 
'3j  Rupture  of  large  vessels  or  nerves  is  very  rare,  and  is  sometimes  the 
result  of  unskilful  reduction  of  an  old  dislocation.  Stretching  and 
crushing  of  the  vessels  and  nerves  are,  however,  more  common.  Crush- 
ing of  the  vessels  occasionally  gives  rise  to  extensive  thrombosis  fol- 
lowed by  gangrene,  especially  if  tlie  dislocation  is  not  promptly  reduced. 
Of  the  injuries  of  nerves,  those  of  the  circumflex,  with  paralysis  of  the 
deltoid  muscle,  are  the  most  frequent. 

Of  the  injuries  of  internal  organs,  I  should  mention  injury  of  Jhe 
spinal  cord  in  dislocation  of  the  vertebrae,  of  the  bladder,  intestine,  and 
pelvic  organs  in  lu.catio  femoris  centralis — i.  e.,  dislocation  of  the 
femur  inwards  through  the  acetabulum,  also  compression_of^jhe  tra- 
ehea  and  cesophagus  in  dislocation  of  the  sternal  end  of  the  clavicle, 
etc.  Prochaska  saw  a  case  in  which  the  head  of  the  humerus  pene- 
trated the  thorax  Ijetween  the  second  and  third  ribs. 

Prognosis  of  Traumatic  Dislocations, — As  regards  the  prognosis,  it  is 
important  for  us  to  consider  (1)  whether  we  have  to  deal  with  a  simple 
or  a  compound  dislocation,  (2j  whether  complications  are  present,  and, 
if  so,  their  nature,  and  (3)  the  region  of  the  body  and  the  particular 
joint  where  the  dislocation  has  occurred.  AVe  usually  expect  perfect 
recovery  to  take  place  in  the  case  of  simple  uncomplicated  dislocations 
which  have  been  successfully  reduced.  Should  the  dislocation  not  be 
reduced,  a  new  joint  or  nearthrosis  is  formed,  as  we  saw  above,  in  the 
abnormal  situation  occupied  by  the  articular  end  of  the  dislocated 
bone,  particularly  if  the  dislocation  were  one  of  the  shoulder  or  hip. 
Occasionally  a  dislocation  will  recur  from  even  a  very  slight  amount 
of  violence,  and  particularly  if  extensive  movements  are  made  with 
the  joint  at  too  early  a  period. 

AVe  sometimes  meet  with  individuals  who  in  this  way  suffer  from 
very  frequent  recurrences  of  the  same  dislocation,  especially  that  of  the 
shoulder,  jaw,  or  the  hip,  and  there  are  people  who  have  dislocated  their 
shoulder  or  jaw^  more  than  flfty  or  one  hundred  times.  These  "  habit- 
ual dislocations,"  as  they  are  called,  have  many  different  causes,  but  they 
are  usually  due  to  a  lax  condition  of  the  capsule  and  its  accessory  liga- 


§122.]  DISLOCATIONS  OF  JOINTS.  71 7 

merits,  which  have  beeoine  stretclu'd  niul  torn  to  such  an  extent  that  tlie 
cavity  of  the  j(jint  is  enlarged,  and  a  dislocation  can  take  place  vvithont 
tlie  occurrence  of  any  fresh  lacfM-ation. 

Treatment  of  Traumatic  Dislocations. — The  treatment  of  recent  un- 
complicated dislocations  consists  in  bringing  the  disj)laced  articular 
end  of  the  bone  back  into  its  socket  by  special  methods  of  reposition, 
and  then  immobilising  the  joint  until  the  rent  in  the  capsule  has 
liealed.  The  reposition  was  at  one  time  carried  out  in  a  very  forcible 
and  rough  way,  and  not  infrequently  with  the  aid  of  mechanical  con- 
trivances, pulleys,  etc. ;  so  that  sometimes  disastrous  consequences — 
such  as  severe  injuries  to  the  skin,  vessels,  nerves,  and  muscles,  or 
fractures — followed,  and  in  some  instances  even  entire  extremities  wei-e 
torn  away.  At  present  we  have  in  chloroform  anjtsthesia  an  excellent 
ineans  of  rendering  the  reduction  of  dislocations  easy  and  paiidess. 
An  attempt  should  first  be  made  to  reduce  a  recent  dislocation  without 
an  anaesthetic,  and  if  this  is  found  to  be  impossible  chloroform  should 
be  administered,  but  with  great  caution,  because  a  collapse  resultin*'- 
in  death  may  easily  take  place,  especially  in  liabitual  drinkers,  who  are 
much  excited  by  the  accident.  The  sooner  after  the  accident  reduction 
is  performed  the  more  easily  it  is  accomplished.  The  movements 
employed  for  reducing  a  dislocation  must  be  carried  out  according  to 
certain  rules,  which  varv  with  the  nature  of  the  case,  and  in  makinof 
them  one  should  always  take  into  consideration  the  shape  of  the  joint 
and  the  nature  and  location  of  the  rent  in  the  capsule.  Impediments 
to  the  reduction  of  recent  dislocations  are  furnished  by  active  contrac- 
tion of  tlie  muscles,  by  the  narrowness  or  unfavourable  location  of  the 
rent  in  the  capsule, '"by  portions  of  capsule  which  still  remain  intact 
though  stretched  and  abnormally  situated,  and'liv  interposition  of  por- 
tions of  the  capsule,  tendons,  muscles,  and  fragments  of  bone.  Active 
contraction  of  the  muscles  and  the  elastic  tension  of  the  soft  parts  are 
overcome  by  chloroform  aiiiTesthesia.  It  is  evident  that  the  movements 
made  in  accomplishing  reduction  must  differ  very  greatly  according  to 
the  nature  of  the  case  and  tlie  site  of  the  dislocation ;  that  sometimes 
rotation,  sometimes  flexion  or  extension,  and  sometimes  abduction  or 
adduction  must  be  performed  ;  and  Kronlein  is  right  in  saying  that  it 
is  not  so  much  the  etiology  of  a  dislocation  as  it  is  its  anatomy  which 
determines  our  method  of  treatment.  By  means  of  the  movements  or 
manipulations  aimed  at  reduction  the  head  of  the  dislocated  bone  is 
brought  opposite  the  rent  in  the  capsule  or  the  socket,  and  then,  with 
a  snapping  sound  or  perceptible  jolt,  caused  to  enter  the  cavity  of  the 
joint.  As  a  rule,  it  is  well  to  combine  with  the  al)ove-mentioned 
manipulations  a  direct  pressure  upon  the  articular  end  of  the  dislocated 


Y18  INJURIES  AND  DISEASES  OF  JOINTS. 

bone.  For  the  methods  of  reducing  tlie  various  dislocations  of  the 
different  joints  I  must  refer  the  reader  to  my  Special  Surgery.  The 
restoration  of  the  normal  contour  and  functions  of  the  joint  will  show 
at  once  that  the  reduction  of  the  dislocation  has  been  successful. 

The  after-treatment  consists  in  keeping  the  re])laced  portions  of 
the  articulation  at  rest  bj  means  of  light,  immobilising  dressings.  In 
dislocations  of  the  shoulder,  for  example,  it  will  suffice  if  the  arm  is 
held  firmly  fixed  by  a  mitella  (see  Fig.  155),  which  is  secured  in  posi- 
tion by  a  few  turns  of  a  bandage  around  the  arm  and  thorax.  In  dis- 
locations of  the  hip  the  jmtient  should  be  kept  in  bed,  a  spica  coxse 
(see  Fig.  143)  applied  about  the  joint,  and  the  limb  immol>ilised  by  a 
cloth  passed  around  the  leg  in  the  region  of  the  knee.  It  is  difficult  to 
keep  some  joints  reduced,  as  is  the  case  with  forward  dislocations  of 
the  head  of  the  radius  and  dislocations  of  the  acromio-clavicular  and 
sterno-clavicular  articulations.  In  such  instances  an  attempt  must 
be  made  to  hold  the  bone  in  place  by  dressings  which  exert  pressure, 
by  pads,  or,  when  necessary,  by  the  use  of  nails  or  bone  sutures.  After 
the  lapse  of  some  eight,  ten,  or  fourteen  days — depending  upon  the 
nature  of  the  case — passive  motion  of  the  dislocated  joint  should  be 
begun  in  order  to  prevent  subsequent  stiffness.  Forced  movements  of 
the  joint  should,  however,  not  be  attempted  during  the  next  few  weeks, 
because  the  healing  of  the  lacerations  in  the  capsule  and  ligaments 
may  be  interfered  witli,  or  the  cicatrices  of  these  structures  may  be 
so  stretched  that  the  dislocation  easily  recurs,  or  even  becomes  ha- 
bitual. 

The  treatment  of  habitual  dislocations,  as  a  rule,  is  very  difficult, 
particularly  in  marked  cases.  Long-continued  rest  of  the  joint  in  one 
position  is  usually  unsuccessful,  because  the  injured  person  has  not 
the  required  patience.  Very  often  nothing  remains  but  to  restrict  the 
movements  of  the  joint  by  means  of  a  suitable  bandage.  In  bad  cases 
it  may  be  well  to  expose  the  joint  under  antiseptic  precautions,  and 
either  suture  the  rent  in  the  capsule  or  resect  the  head  of  the  bone. 
Genzmer  successfully  treated  two  cases  of  habitual  dislocation — one 
of  the  shoulder  and  the  other  of  the  jaw — by  the  subcutaneous  injec- 
tion of  pure  tincture  of  iodine  (0*5  to  0*75  cubic  centimetres  tinct.  iodi 
injected  by  a  hypodermic  syringe  at  intervals  of  three  to  four  days, 
until  six  to  eight  injections  have  been  made).  Subcutaneous  injections 
of  absolute  alcohol  might  also  be  tried. 

In  fresh  dislocations  which  are  irreducible  an  aseptic  arthrotomy 
should  be  performed- — i.  e.,  the  site  of  the  dislocation  should  be  ex- 
posed by  an  incision  and  the  head  of  the  bone  then  brought  back  into 
place,  or  resected   if  reduction  is  otherwise  impossible.     But  recent 


§  122.J  DISLOCATIONS   OF  JOINTS.  Yl9 

simple  dislocations  sekloiu  riMjuire  opemtive  interference,  since  reduc- 
tion can  generally  be  accomplished,  especially  if  chloroform  is  used. 

One  should  first  try  to  reduce  even  old  dislocations  by  the  usual 
method,  though  they  may  have  existed  for  weeks,  months,  or  years  ; 
luxations  t.)f  the  shoulder  and  also  of  the  hi})  have  thus  been  success- 
fully bi'oui^ht  back  into  place  two  years  after  the  accident.  The  possi- 
bility of  i-eduction  in  these  cases  de})ends  mainly  upon  the  extent  of 
the  injuries  which  the  soft  pai'ts  have  suffered,  upon'the  greater  or  less 
degree  of  iixation  of  the  dislocated  articular  end  of  the  bone  in  its  new 
position,  and,  tinally,  upon  whether  the  joint  cavity  is  much  diminished 
in  size  or  quite  obliterated.  After  thoroughly  anaesthetising  the 
patient  with  chloroform,  the  same  maiiij)ulations  are  employed  for  the 
reduction  of  old  dislocations  as  for  those  which  are  recent,  the  articular 
end  of  the  bone  being  first  freed  by  rotatory  movements.  The  manipu- 
lations aimed  at  reduction  should  be  made  with  great  care  so  as  not  to 
injure  the  bones  or  soft  parts.  The  mechanical  contrivances  once  so 
extensively  used,  such  as  pulleys,  windlasses,  etc.,  have  become  obsolete 
and  have  only  a  historic  interest.  Even  though  the  reduction  is  suc- 
cessfully accomplished  a  good  result  is  not  always  assured,  as  the  joint 
often  remains  stiff  in  spite  of  massage,  electricity,  and  active  and  pas- 
sive motion.  If  reduction  is  impossible,  the  dislocation  should  be  ex- 
posed by  an  incision — i.  e.,  arthrotomy  should  be  performed  and  the  head 
of  the  bone  returned  to  its  normal  position,  especially  in  those  cases  in 
which  the  limb  has  become  useless  owing  to  malposition,  or  in  which 
the  dislocated  articular  end  of  the  bone  causes  pain  and  paralysis  by 
pressing  upon  the  nerves.  In  such  instances  resection  of  the  articular 
end  of  the  bone  will  often  be  necessary  as  a  preliminary  step  in  per- 
forming reduction.  At  the  hip  the  position  of  the  limb  is  sometimes 
best  corrected  by  osteoclasis  or  subtrochanteric  osteotomy.  In  other 
cases  of  old  irreducible  dislocations  one  may  try  to  make  as  good  a 
nearthrosis  as  possible  by  means  of  massage,  passive  motion,  electricity, 
and  warm  baths. 

Dislocations  in  which  there  is  an  opening  at  the  same  time  into  the 
joint  are  treated  by  the  same  rules  that  apply  to  wounds  of  joints  (see 
page  723).  Under  these  circumstances,  also,  reduction  should  be  per- 
formed as  promptly  as  possible,  taking  every  antiseptic  precaution  and 
providing  for  drainage  of  the  joint.  According  to  Drewitz,  reduction 
without  resection  of  the  head  of  the  bone  gave,  even  in  preantiseptic 
times,  movable  joints  in  forty  per  cent,  of  the  cases.  If  diificulties 
are  met  with  in  performing  reduction  the  knife  should  be  made  use  of, 
and  when  reduction  has  been  accomplished  the  joint  should  be  care- 
fully drained  and  immobilised.     If  the  soft  parts  have  been  very  much 


^20  INJURIKS   AM)   DISEASES   OF  JOINTS. 

injured  pennaiieiit  irrio-atioii  should  be  em])lojed.  Resection  of  tlie 
head  of  the  dislocated  bone  is  indicated  in  cases  complicated  by  com- 
minuted fractures,  extensive  injury  to  the  soft  parts,  suppuration 
within  the  joint,  or  where  reduction  is  impossible  by  other  means.  If 
sepsis  has  already  made  its  appearance  prompt  amputation  or  disarticu- 
lation may  be  necessary. 

If  both  dislocation  and  fracture  occur  together,  it  should  be  our 
lirst  aim  to  reduce  the  dislocation  when  this  is  possible,  using,  for  ex- 
ample, direct  pressure  upon  the  articular  fragment  in  the  case  of  dislo- 
cation and  fracture  of  the  humerus  at  the  shoulder  joint.  In  other 
instances  reduction  of  the  dislocation  may  be  impossible,  and  the  frac- 
ture must  first  be  allowed  to  heal  before  the  dislocation  is  attended  to. 
In  suitable  cases  operative  measures  must  be  undertaken — i.  e.,  the  seat 
of  injury  should  be  exposed,  and  whatever  measures  the  condition  calls 
for  adopted.  The  prognosis  of  all  dislocations  which  are  complicated 
by  fracture  should  be  looked  upon  as  doubtful  as  regards  restoration  of 
the  normal  mobility  of  the  joint. 

The  other  complications,  such  as  injuries  to  vessels  and  nerves,  are 
to  be  treated  in  the  usual  way  (see  §  88). 

Dislocation  of  the  semilunar  cartilages  of  the  knee  rarely  occurs  inde- 
pendently of  other  changes  in  the  joint.  Habitual  dislocation  of  these  car- 
tilages has  been  observed,  the  most  common  variety  being  a  displacement  of 
the  inner  cartilage  forwards,  due  to  forced  flexion  of  the  knee  joint  combined 
with  outward  rotation  of  the  foot,  or.  rather,  leg.  The  displaced  cartilage  can 
be  felt  on  the  anterior  border  of  the  joint,  the  knee  is  somewhat  flexed,  and 
complete  extension  is  impossible. 

For  a  description  of  dislocations  of  tendons  and  nerves  see  pages  509,  510. 

II.  Pathological  or  Spontaneous  Dislocations  are  ol^served  in  the 
course  of  diseases  of  joints  either  as  a  result  of  'an  abnormal  stretch- 
ing or  lax  condition  of  the  capsule  and  ligaments,  or  of  changes  within 
the  joint  such  as  those  caused  by  arthritis  deformans  or  caries.  Under 
such  circumstances  either  an  incomplete  or  a  complete  dislocation  takes 
place,  coming  on  gradually  and  brought  about  by  the  weight  of  the 
limb,  or  suddenly  from  some  slight  traumatism,  muscular  action,  etc. 

We  distinguish  :  1.  Distentimi  Dislocations,  due' to  a  stretching  or 
lax  condition  of  the  capsule  and  ligaments  of  the  joint  caused  by  a 
serous,  sero -fibrinous,  or  more  rarely  suppurative  effusion.  Complete 
and  incomplete  dislocations  of  this  kind  are  especially  common  in  the 
course  of  metastatic  inflammations  of  joints  with  large  collections 
of  fluid,  such  as  occur  in  typhoid  fever,  small-pox,  measles,  scar- 
let fever,  diphtheria,  puerperal  fever,  and  pyfioinia.  '"  The  capsule  and 
ligaments  of    a  joint — the  shoulder,  for  example— may   also   become 


i$  122.] 


DISLOCATIONS  OP  JOINTS. 


721 


stretched  in  cases  of  inii.scnilar  atr()])liy  and  ])aralj.sis.  Under  these 
conditions  tlie  muscles  are  not  capable  of  supporting  the  extremity,  and 
thus  allow  displacements  of  the  joint  surfaces  to  take  place  either  gradu- 
ally or  suddenly.  The  voluntary  dislocations  mentioned  on  page  712 
are  likewise  looked  upon  by  some  authors  as  distention  dislocations. 

Quite  recently  Verneuil  has  called  attention  to  dislocations  which  occur 
during  acute  ai'ticular  rheumatism  and  run  a  course  exactly  hke  that  of 
traumatic  dislocations.  In  all  cases  the  luxations  took  place  suddenly  and 
spontaneously,  and  could  be  reduced  very  easily  under  an  anaesthetic.  Ver- 
neuil tlnnks  that  tliese  dislocations  are  caused  by  nmscular  action  and  a  lax 
condition  of  the  ligaments. 

2.  Destruction  Dislocations. — The  most  common  form  of  jiatlio- 
logical  dislocation  is  due  to  a  carious  destruction  of  the  joint  surfaces 
combined  with  corresponding  changes  in  the  capsule  and  ligaments. 
In  this  category  belong  the  so-called  "  wandering  of  the  acetabulum  "  in 
coxitis  (page  674,  Fig.  374)  and  the  spondylolisthesis — i.  e.,  the  slipping 
down  of  the  last  lumbar  vertebra  into  the  pelvis  in  cases  of  tubercular 
destruction  of  the  corresponding  intervertebral  ligaments  (see  §  114). 

3.  Deformity  Dislocations,  which  are  the  result  of  changes  in  the 
shape  of  the  bony  parts  of  the  joint  due  to  an  atrophy  of  bone  with- 
out suppuration  and  without 
the  production  of  granula- 
tions. They  most  commonly 
occur  in  connection  with  ar- 
thritis deformans  (see  page 
686,  Fig.  380). 

For  the  course,  diagnosis, 
and  treatment  of  pathological 
dislocations  see  §  113,  §  114, 
§  119  (Inflammations  and  De- 
formities of  Joints),  and  the 
above  description  of  traumat- 
ic dislocations. 

III.  Congenital  Disloca- 
tions. —  Congenital  disloca- 
tions are  mainly  the  result  of 
anomalous  or  arrested  fcetal  development.  They  are  most  common  at 
the  hip  (Fig.  394),  being  very  rarely  found  in  the  rest  of  the  joints,  and 
are  occasionally  combined  with  other  anomalies  of  development,  such 
as  club-foot,  spina  bifida,  and  ectropion  vesicae.  These  congenital  dis- 
locations, which  take  place  in  utero,  should  not  be  confused  with  the 
traumatic  ones  which  take  place  during  delivery  and  are  due  to  extrac- 
46 


Fig.  394.— Congenital  dislocation  of  the  left  hip  in  a 
si.x-moiith.s-old  girl ;  a,  remains  of  the  cap.sule 
■winch  has  been  dissected  away  ;  5,  undeveloped 
acetabulum. 


722 


INJUKIES   AND   DISEASES  OF  JOINTS. 


tion  of  the  child.  This  latter  form  of  dislocation  is,  however,  extreme- 
ly rare,  fractures,  especially  at  the  epiphysis,  on  account  of  the  latter's 
slight  power  of  resistance,  being  much  more  common. 

Investigations  relating  to  the  Pathology  and  Etiology  of  Congenital  Dislo- 
cations.—These  investigations  have  to  do  almost  exclusively  with  congenital 
(Uslocations  of  the  hip.  I  had  an  opportunity  at  one  time  of  examining  a 
dislocation  of  this  kind  in  a  female  child  six  months  old  (Fig.  394).  I  found 
that  the  acetahulum  was  very  imperfectly  developed,  that  the  neck  of  the 
femur  formed  an  obtuse  angle  with  the  shaft,  and  that  the  ligamentum  teres 
was  so  much  thickened  and  lengthened  that  the  head  of  the  femur,  which 
was  situated  near  the  anterior  superior  spine,  did  not  have  sufficient  room  in 
the  shallow  acetabulum.  The  pelvis  was,  moreover,  asymmetrical,  but  the 
capsule  of  the  joint  was  normal. 

The  congenital  dislocation  of  the  hip  usually  Ijelongs  to  the  iliac  variety, 
the  head  being  in  contact  with  the  ilium.     Lordosis  of  the  vertebral  colunm 
is  present,  especially  in  bilateral  dislocations,  and  the  pa- 
tients have  a  very  characteriscic  gait,  like  that  of  a  duck. 

The  main  cause  of  congenital  dislocation  of  the  hip  is 
probably  to  be  found  in  an  imperfect  development  of  the 
acetabulum  or  the  cotyloid  ligament,  and  its  occurrence  is 
favoured  by  extreme  flexion  and  adduction  of  the  thighs 
of  the  foetus  (Fig.  395,  Dupuytren,  Roser).  A  very  small 
uterus,  which  exerts  abnormal  pressure  upon  the  foetus, 
thus  causing  the  latter  to  assume  a  cramped  position,  may 
possibly  have  a  deleterious  influence  upon  the  develop- 
ment of  the  hip  joint.  The  obtuse  angle  which  the  neck 
of  the  femur  makes  with  the  shaft  (Fig-.  394)  should  also  be 
noted,  as  this  is  probably  not  always  a  secondary  condition, 
but  one  which  may  sometimes  develop  primarily  from  the 
above-mentioned  cramped  position  of  the  foetus  brought 
about  by  a  uterus  which  is  deficient  in  size.  Owing  to  the 
obtuse  angle  which  the  neck  of  the  femur  forms  with  the 
shaft  (Fig-.  394),  the  head,  as  it  were,  grows  past  the  acetab- 
ulum instead  of  into  it.  Other  cases  of  congenital  dislo- 
cation are  probably  the  result  of  an  abnormally  long  and 
thick  ligamentum  teres,  which,  as  in  the  case  I  examined, 
does  not  give  the  head  sufficient  room  in  the  acetabulum. 
Another  important  fact,  from  an  etiological  point  of  view,  is  that  congenital 
dislocations  of  the  hip  are  m^^ch  more  common  in  females  than  in  males,  87"6 
per  cent,  of  all  cases  occurring  in  the  former  sex. 

From  careful  examinations  which  I  have  made  of  the  foetal  pelvis,  I  be- 
lieve that  this  latter  fact  can  be  explained  by  the  comparatively  vertical  posi- 
tion of  the  ilium  in  females,  which,  in  conjunction  with  the  abnormal  angle 
formed  by  the  neck  of  the  femur  with  the  shaft,  readily  allows  the  head  to 
leave  the  shallow  acetabulum  and  ghde  up  on  to  the  ilium. 

It  follows  from  what  has  been  said  that  the  congenital  dislocations  of  the 
hip  are  undoubtedly  to  be  ascribed  to  anomalies  in  the  development  of  the 
foetus  due  to  various  causes. 


Fi(i.  395.— The  man- 
ner in  which  a 
eontreniUil  dislo- 
cation <it'  the  liip 
is  prodiK'cd :  tlie 
leg  ot  the  f'(jetus  is 
forced  to  assume 
an  abnormally 
adducted  position 
l«y  a  uterus  which 
is  too  small  (W. 
Roserj. 


§  !■-'-■ 


DISLOCATIONS   OF  JOINTS. 


n^ 


The  rare  eases  of  eongenital  dislocations  of  otlier  joints  of  the  body 
are  probably  also  due  to  fcetal  anomalies  of  development.  Congenital 
subcoracoid,  subacromial,  and  infraspinous  dislocations  of  the  shoulder 
have  been  reported,  as  well  as  congenital  dislocations  of  the  elbow, 
wrist,  knee,  and  ankle.  At  the  elbow,  congenital  dislocation  of  the 
head  of  the  radius — backward,  outward,  forward,  or  inward — is  the 
most  Common. 

The  symptoms,  diagnosis,  and  treatment  of  congenital  dislocations 
of  the  dilferent  joints  are  taken  up  at  length  in  the  Special  Surgery, 
and  1  will  only  brielly  state  here  that  the  prognosis  is  usually  unfavour- 
able, although  fairly  good  results 
have  been  obtained  in  dislocations 
at  the  knee.  Effective  treatment 
is  generally  very  difficult,  as  the 
dislocations  are  ordinarily  not  rec- 
ognised until  too  late.  Patients  do 
not,  as  a  rule,  come  under  observa- 
tion until  the  joint  has  undergone 
such  changes  that  a  reduction  is  no 
longer  possible.  Little  or  no  bene- 
fit results  from  innnobilisation  car- 
ried out  for  a  long  time,  or  from 
extension  or  supporting  apparatus. 
Recently  Konig  and  others  have 
tried  to  expose  the  head  of  the  fe- 
mur in  cases  of  congenital  disloca- 
tion of  the  hip  by  Langenbeck's  in- 
cision, and  then  to  free  the  head 
sufficiently  by  subperiosteal  divis- 
ion of  the  muscular  insei'tions  and 
soft  parts  to  enable  it  to  be  drawn 
down  into  the  region  of  the  acetab- 
ulum. If  there  is  no  acetabulum, 
or  if,  as  is  usual,  it  is  only  rudimen- 
tary, it  must  be  chiselled  out,  or  an 
artificial  one  made  by  means  of  a 
flap  of  periosteum  and  bone.  I  have  found  it  very  difficult,  especially 
in  older  children,  to  keep  the  head  in  the  neighbourhood  of  the  acetab- 
ulum,  either  immediately  after  the  operation  or  later,  when  the  wound 
has  healed,  on  account  of  the  obtuse  angle  made  by  the  neck  of  the  fe- 
mur with  the  shaft.  I  obtained,  however,  an  excellent  result  in  the 
case  of  a  boy  three  years  old  with  a  unilateral  dislocation,  because  the 


Fig.  396. 


-Double  eoiiifenital  dislocation  of 
the  hip. 


724  INJURIES   AND   DISEASES  OF  JOINTS. 

acetabulmn  was  abnormally  deep,  so  that  the  head  found  sufficient  sup- 
port, even  without  enlarging  the  acetabulum  artificially.  This  was  the 
deepest  acetabulum  that  1  have  ever  seen  in  a  congenital  dislocation ; 
and  as  tlie  ligamentum  teres  had  ru])tured,  I  doubt  if  this  was,  after  all, 
a  true  congenital  dislocation.  It  was,  more  likel_y,  a  traumatic  disloca- 
tion, acquired  at  a  very  early  period — an  injury  which,  as  is  well  known, 
is  extremely  rare  in  the  first  years  of  life.  .: 

§  123.  Wounds  of  Joints. — Wounds  of  joints  consist  of  punctured, 
incised,  and  contused  wounds,  and  wounds  which  are  complicated  with 
fracture,  including  gunshot  wounds  (see  §  12-1:).  Any  wound  which 
opens  a  joint — a  so-called  penetrating  wound — even  though  extremely 
small,  should  be  looked  upon  as  a  very  serious  injury,  since  it  may 
more  or  less  completely  destroy  the  function  of  the  joint,  and  even 
imperil  the  life  of  the  patient.  The  escape  of  synovial  fiuid  is  a  symp- 
tom which  indicates  beyond  a  doubt  that  the  joint  has  been  opened. 
The  prognosis  of  penetrating  w^ounds  of  joints  is,  however,  much  more 
favourable  than  it  was  before  the  introduction  of  the  antiseptic  method 
of  treating  wounds,  and  we  now  have  no  fear  of  opening  a  joint 
aseptically  with  the  knife  or  trocar.  But  the  conditions  are  entirely 
different  in  the  case  of  accidental  wounds  made  with  an  unsterilised 
instrument,  or  of  gunshot  wounds  into  which  dirty  pieces  of  clothing 
have  perhaps  entered.  Under  such  circumstances  germs  of  infection 
can  readily  make  their  way  into  the  joint,  and  with  great  rapidity  cause 
violent  inflammation. 

The  course  of  a  penetrating  wound  of  a  joint  depends  very  largely 
upon  whether  or  not  germs  of  infection  have  gained  access  to  the  joint 
at  the  time  of  the  accident,  or  afterwards. 

"We  shall  first  discuss  the  cases  in  which  everything  is  most  favour- 
able— i.  e.,  in  which  no  infection  of  the  wound,  a  punctured  one,  for 
example,  has  taken  place.  The  course  of  such  a  Avound  will  then  be 
as  follows :  The  synovia  makes  its  appearance  at  the  time  of  the  acci- 
dent, but  soon  ceases  to  flow  out,  and  the  wound  becomes  agglutinated 
and  heals  up  without  causing  any  inflammation  or  disturbance  of  func- 
tion in  the  joint.  In  other  cases  a  mild  inflammation  occurs,  taking 
the  form  of  a  synovitis  serosa  or  serofibrinosa. 

The  course  of  an  infected  wound  of  a  joint  is  quite  different.  In- 
fection may  take  place  at  the  time  of  the  accident  or  later,  and  is 
then  due  to  improper  treatment  or  dirty  probes,  or  to  the  fact  that 
the  patient  pays  no  attention  to  the  wound,  and  walks  about,  thus,  by 
his  movement  of  the  parts,  permitting  air  and  infectious  germs  to 
have  free  access  to  the  joint.  In  soihe  cases  the  wound  has  already 
united,  and  then  on  the  third  to  the  fifth  day  manifestations  of  inflam- 


J?  12:5.]  WOUNDS  OF  JOINTS.  725 

Illation  smkleiily  make  their  appearance,  and  rapidly  increase  in 'sever- 
ity. Tlie  joint  is  swollen,  tense,  and  very  painful,  the  skin  is  red  and 
feels  hot,  and  there  is  high  fever.  If  the  agglutinated  borders  of  the 
wound  are  separated  by  a  probe,  or  if  the  sutures  are  removed,  pus 
immediately  makes  its  appearance.  Other  cases,  especially  those  in 
which  there  is  a  large  effusion  of  blood,  run  a  more  acute  course,  and 
the  local  and  general  symptoms  of  suppuration  in  the  joint  come 
on  within  twenty-four  hours  after  the  injury.  These  are  the  most 
unfavourable  ones,  and  unless  the  infected  contents  are  promptly 
removed  by  freely  opening  up  the  joint,  followed  by  drainage 
and  antiseptic  irrigation,  or,  if  necessary,  by  resection,  acute  gan- 
grene of  the  joint  may  rapidly  follow,  with,  perhaps,  constitutional 
sepsis. 

In  another  group  of  cases  the  course  is  more  subacute,  and  though 
the  exudate  within  the  joint  is  very  large  it  is  not  noticeably  suppu- 
rative in  character,  but  looks  like  cloudy  synovia  mixed  with  flakes  con- 
taining pus-cells  (see  §  113). 

The  flnal  outcome  of  an  infected  wound  of  a  joint  varies,  though 
if  it  receives  antiseptic  treatment  early  enough  recovery  is  assured. 
In  some  cases,  after  a  longer  or  shorter  time,  the  suppurative  inflam- 
mation gradually  gets  well  spontaneously  without  any  particular  anti- 
septic treatment,  but  in  others  which  are  not  properly  attended  to  the 
suppuration  becomes  progressive,  breaks  through  the  capsule  of  the 
joint,  and  gives  rise  to  suppuration  in  the  neighbourhood,  "while  the 
inflammation  in  the  joint  itself  apparently  diminishes  in  intensity. 
Such  suppurative  processes  not  infrequently  run  a  very  tedious  course, 
gradually  going  on  to  pyaemia,  to  which  or  to  extreme  exhaustion  the 
patient  succumbs.  The  worst  cases  are  those  in  which  death  occurs 
from  acute  septicaemia  within  a  few  days.  These  septic  or  gangrenous 
inflammations  of  joints  may  be  caused  by  a  very  slight  injury,  such  as 
puncture  of  the  joint  with  a  sewing  needle,  and  they  may  run  such  a 
rapid  course  that  even  on  the  fourth  or  fifth  day  death  from  septicaemia 
cannot  be  prevented  even  by  amputation  or  disarticulation.  AYe  have 
already  described  the  course  and  outcome  of  the  different  varieties  of 
acute  inflammations  of  joints  in  the  chapters  devoted  to  Joint  Inflam- 
mations. 

The  Repair  of  Wounds  in  Cartilage.— Gies  has  made  experiments  on 
young  dogs  with  reference  to  the  rejjair  of  wounds  made  in  cartilage  and  has 
come  to  the  conclusion  that  clean  aseptic  wounds  in  this  tissue  never  heal, 
but  remain  permanently  unchanged,  while  wounds  which  are  made  in  the 
presence  of  micro-organisms  heal  up  so  completely  as  not  to  leave  any  or 
scarcely  any  traces  behind  them. 


726  INJURIES   AND   DISEASES   OF   JOINTS. 

The  escape  of  synovial  fluid  in  all  recent  cases  which  come  under 
observation  immediately  after  the  reception  of  the  injury  has,  as  we 
remarked  before,  a  very  important  bearing  upon  the  diagnosis  of  pene- 
trating wounds  of  a  joint.  In  some  instances  in  which  the  joint  is 
laid  wide  open  the  ex])Osed  articular  cartilages  may  be  recognized  at 
the  Hrst  glance.  But  not  infrequently  the  puncture  or  other  wound  is 
already  closed,  so  that  it  is  doubtful  whether  the  joint  has  been  opened 
or  not,  and  under  these  circumstances  we  must  quietly  wait  for  further 
developments.  A  warning  should  be  given  here  against  probing 
wounds  too  freely  in  the  neighbourhood  of  a  joint. 

Treatment  of  Wounds  of  Joints. — Every  wound  of  a  joint,  even  the 
most  trivial,  should  be  treated  with  the  greatest  care.  We  shall  not 
discuss  the  treatment  of  gunshot  wounds  of  joints,  as  they  will  be 
taken  up  later  in  §  124-. 

Absolutely  fresh  cases  without  much  effusion  into  the  joint,  and 
without  apparent  infection,  are  treated  by  disinfection  of  the  wound 
and  its  neighbourhood.  I  do  not,  as  a  rule,  suture  such  wounds,  but 
merely  dust  them  with  iodoform,  cover  them  with  iodoform  or  bichlo- 
ride gauze  which  has  been  moistened  in  a  l-to-1,000  solution  of  bichlo- 
ride of  mercury,  and  over  this  place  sterilised  cotton.  Large  wounds 
should  be  packed  with  iodoform  or  sterilised  gauze.  The  antiseptic 
occlusive  dressing  should  be  as  large  as  possible,  and  the  joint  must  be 
carefully  immobilised  by  splints.  The  time  for  changing  the  dressings 
depends  upon  the  subsequent  course  of  the  injury,  and  very  often  asep- 
tic healing  takes  place  without  changing  the  dressing  at  all.  But  should 
fever  make  its  appearance,  and  the  patient  complain  of  pain,  the  dress- 
ing must  be  changed  immediately.  If,  upon  taking  off  the  dressing,  it 
is  evident  that  the  joint  has  become  infected  and  that  an  acute  suppu- 
rative inflammation  has  developed,  thorough  disinfection  and  drainage 
of  the  joint  must  be  begun  at  once.  The  joint  should  be  freely  opened, 
all  pockets  within  it  disinfected  with  a  l-to-l,(>00  bichloride  solution, 
and  any  blood-coagula  that  may  be  present  carefully  removed.  Short 
and  thick  drainage  tubes — preferably  of  glass — must  be  inserted  in 
those  places  where  they  can  most  elfectually  help  to  carry  off  the  dis- 
charges. In  suitable  cases  the  wound  is  packed  with  iodoform  gauze 
or  sterilised  mull,  and  it  is  also  of  the  greatest  importance  to  secure 
immobilisation  of  the  joint.  The  dressings  must  be  changed  often,  de- 
pending upon  the  height  of  the  temperature.  Not  infrequently  one 
has  the  pleasure  of  seeing  that  this  treatment  is  followed  by  excellent 
results,  that  the  inflammation  of  the  joint  is  averted,  and  that,  even  in 
cases  where  one  could  hardly  have  expected  it,  perfect  mobility  of  the 
joint  is  regained  despite  the  fact  that  suppurative  arthritis  has  occurred. 


g  1'24.]  GUNSHOT  INJURIES.  7*27 

If,  in  spite  of  (li>infi'cti()ii  and  (Iraiiiay'e  of  the  joint,  severe  consti- 
tutional synij)totns  make  their  aj)i)earanee,  or  if  the  suj)j)uration  that  is 
present  is  very  extensive,  so  that  draina<^e  of  the  joint  j)resents  great 
difficulties,  resection  is  then  indicated  ;  or,  if  general  systemic  infection 
threatens,  the  focus  of  infection  must  be  removed  by  amputation  or 
disarticulation. 

If  the  patient  comes  under  treatment  aftei-  su|i|)uration  has  already 
begun,  antiseptic  incision  and  drainage,  or  packing  of  the  joint  with  or 
without  resection,  or  even  amputation  are  indicated,  dejiending  upon 
the  amount  of  suppuration  and  the  length  of  time  the  disease  has  lasted. 
In  opening  up  old  infected  cases  of  this  kind  one  should  not  be  afraid 
of  making  too  many  incisions  into  the  different  parts  of  tlie  joint. 
Continuous  antiseptic  irrigation  will  often  be  found  a  most  excellent 
aid  in  the  subsequent  treatment  (see  page  178).  Any  complications 
that  may  be  encountered — fractures,  for  instance — are  to  be  treated  in 
the  usual  way.     (See  page  GOO,  Treatment  of  Compound  Fractures.)      . 

Y 


Appendix. 

Giuisliot  wounds.     Militarj^  practice. 

§  124r.  Gunshot  Injuries. — In  connection  with  wounds  of  joints,  we 
shall  give  a  short  description  of  the  gunshot  wounds  which  have  already 
been  referred  to  several  times  in  speaking  of  injuries  to  the  different 
tissues.  We  must,  of  course,  confine  ourselves  here  merely  to  a  brief 
sketch,  and  whoever  cares  to  become  better  acquainted  with  this  ex- 
tremely interesting  subject  should  read  the  excellent  works  of  Stro- 
nieyer,  Pirogoff,  Langenl)eck,  Billroth,  Esmarch,  etc.  The  literature 
of  gunshot  wounds  and  military  surgery  is  very  extensive.  Of  the 
older  l)ooks,  I  should  speak  especially  of  the  memoirs  of  Larrev,  the 
famous  army  surgeon  of  Napoleon  I,  and,  amongst  English  works,  of 
The  Principles  of  Military  Surgery,  by  John  Ilennen. 

Gunshot  wounds  are  essentially  contused  and  lacerated  wounds,  and 
are  most  commonly  caused  by  hand  firearms.  The  projectiles  of  the 
latter  (shot-guns,  revolvers,  pistols)  are  generally  cylindrical  or  shaped 
like  an  acorn,  and  are  usually  made  of  lead.  The  bullets  used  in  mod- 
ern weapons — i.  e.,  those  of  small  calibre  (eight  millimetres),  at  present 
employed  by  the  European  armies — are  long  and  cylindrical,  and  con- 
sist of  a  lead  core  encased  in  steel.  Owing  to  this  steel  covering  the 
bullets  have  great  strength  and  retain  their  shape  when  they  strike  a 
bone  or  pass  through  the  body.  The  penetrating  power  of  these  bullets 
is,  as  we  shall  see,  very  extraordinary,  but  they  are  nevertheless  more 


728  INJURIES   AND   DISEASES   OF  JOINTS. 

liumaue  than  the  lead  bullets.  The  latter  become  so  soft  from  friction 
as  they  pass  through  the  barrel  of  the  gun  and  the  air  that  thej  change 
their  shape  very  materially  and  break  up  into  single  pieces,  so  that  a 
sort  of  explosion  results.  AVlien  they  strike  bone,  for  example,  they 
become  flattened  out,  split,  shattered,  or  broken  up  into  irregular, 
pointed  fragments  of  lead.  In  the  case  of  shots  fired  from  a  short  dis- 
tance the  bullet  is  heated  to  a  very  high  temperature,  and,  as  we  shall 
see,  it  is  under  these  circumstances  that  its  explosive  action  is  most 
likely  to  take  place. 

Bullets  cause  the  following  injuries  :  1.  The  mildest  form  of  gun- 
shot injury  is  contusion  of  the  soft  parts,  with  suggillation  and  without 
•  a  wound.  These  contusions  of  the  skin  or  soft  parts  are  usually  made 
by  spent  balls  coming  from  a  great  distance.  In  rare  cases  subcutane- 
ous fractures  are  also  produced  in  this  manner.  Occasionally  the  con- 
tused, midivided  skin  is  pressed  inwards  like  a  pouch,  thus  causing, 
when  the  bullet  strikes  upon  the  abdomen,  contusion  and  laceration  of 
internal  organs,  of  which  the  liver  may  be  one.  Moreover,  bullets 
which  have  a  great  velocity  can  be  so  checked  by  striking  a  watch, 
purse,  pocketbook,  pieces  of  leather  on  the  uniform,  etc.,  that  only  a 
contusion  without  any  wound  results.  Bullets  of  small  calibre  with  a 
covering  of  nickel  or  steel  cannot  be  stopped  in  this  way,  as  they  have 
an  extraordinary  penetrating  power. 

2.  Ftirroioed  wounds  are  caused  by  bullets  which  graze  the  surface 
of  the  body  and  carry  with  them  a  portion  of  the  skin,  so  that  a  more 
or  less  deep  furrow  is  formed. 

3.  The  most  common  gunshot  injuries  are  txihular  loounds — i.  e., 
the  ball  passes  through  the  skin  and  enters  the  soft  parts,  where  it 
either  remains  lodged  (so-called  blind  shot  canal)  or  comes  out  again  at 
another  part  of  the  body  ("  seton  shot"),  thus  making  an  opening 
where  it  entered  and  one  where  it  emerged.  The  differentiation  of 
the  points  of  entrance  and  exit  is  of  importance  notably  from  a  medico- 
legal point  of  view.  The  point  of  entrance  is  usually  more  or  less  in- 
dented, depending  upon  the  size  of  the  bullet,  and  is  coloured  bluish- 
black,  while  the  exit  opening  is  generally  smaller,  and  looks  more  like 
a  tear.  These  points  of  difference  do  not,  however,  always  hold  good, 
as  the  opening  of  exit  is  sometimes  larger  than  that  of  entrance,  partic- 
ularly when  a  bone  is  splintered  or  when  the  ball  changes  its  shape  or 
becomes  broken  into  pieces.  Occasionally  several  points  of  exit  are 
found,  especially  if  the  bullet  has  been  fired  at  short  range — a  thing 
which  produces  an  effect  like  an  explosion,  shattering  the  bone  into 
separate  splinters,  which  perforate  the  skin.  The  burning  of  the  integu- 
ment is  often  very  extensive  when  the  revolver  or  pistol  has  been  dis- 


?  l-^J.J 


GUNSHOT    INMURIKS. 


729 


charged  close  to  tlie  body,  as  in  attempts  at  suicide,  and  then,  owing  to 
the  heahng  into  the  tissues  of  small  particles  of  powder,  the  skin  often 
remains  of  a  greyish-black  colour  for  the  rest  of  life.  The  same  is  true 
of  small  shot,  which,  when  fired  from  near  at  hand,  can  also  cause  very 
extensive  destruction  of  the  regi(^n  where  they  strike,  and  particularly 
severe  shock,  giving  rise  to  such  marked  symptoms  of  collapse  that  the 
patient  may  die  soon  after  the  injury.  C^uite  recently  I  saw  a  bad  case 
of  c()lla])se  occasioned  in  this  way,  in  a  hunter  who  was  struck  by  fifty- 
two  pieces  of  shot ;  but  in  spite  of  having  sustained  wounds  of  his 
lungs,  pericardium,  and  intestine,  the  patient  recovered. 

The  direction  of  the  canal  formed  by  the  ball  in  its  passage"  through 
the  body  is  sometimes  very  peculiar,  and  instances  are  recorded  where 
it  encircled  the  thorax  close  to  the  ribs  without  injuring  the  pleura  or 
the  lungs.  The  entrance  into  a  gunshot  wound  of  unclean  foreign 
bodies,  such  as  bits  of  cloth,  leather,  or  linen  from  the  clothing,  has  a 
very  important  bearing  upon  the  subsequent  course  of  the  injury,  as 
substances  like  these  are  extremely  apt  to  give  rise  to  infection  pro- 
vided the  micro-organisms  they  contain  are  not  killed  by  the  intense 
heat  of  the  bullet. 

The  modern  artillery  projectiles,  such  as  grenades,  cannon  balls, 
shells,  etc.,  often  give  rise  to  severe 
injuries  similar  to  those  caused  by 
machinery  in  times  of  peace ;  en- 
tire extremities  may  be  torn  from 
the  body,  and  death  can  be  instan- 
taneous. But  slight  wounds,  such 
as  contusions  and  superficial  lace- 
rated wounds,  are  likewise  fre- 
quently caused  by  the  same  mis. 
siles. 

The  gunshot  injuries  of  bone 
are,  as  a  rule,  (1)  comjpoiind  com- 
minnU'd  fractures.  The  number 
of  fragments  is  sometimes  very 
large,  and,  in  addition,  there  are 
many  fissures,  as  illustrated  in  Figs, 
332,  336-338,  397.  The  splinters 
of  bone  are  often  driven  into  the 
soft  parts  or  even  through  the  skin,  forming,  as  we  stated  before,  sev- 
eral exit  openings.     Kot  infrequently  the  bone  is  crushed  to  a  pulp. 

There  are  also  found  in  bone  (2)  tithular  gunshot  wonnds  or 
punched-out  wounds,  with  or  without  splinters  or  tissures.     The  latter, 


Fig.  397. — Gun.-bot  injury  of  the  skull  fin  a 
Russian  soldier  killed  Aug.  30tli,  before 
Plewna),  with  numerous  fissures  which  run 
from  one  opening  («)  to  the  other  (6)  (Berg- 
mann). 


730  IXJURII-:S  AND   DISEASES  OF  JOINTS. 

in  Fio".  397,  unite  the  points  a  and  h  of  entrance  and  exit  of  the  mis- 
sile. (3)  Suhcutaneous fractures  caused  by  a  spent  ball  have  already 
been  spoken  of.  The  mildest  form  of  injury  to  bone  is  (4)  contusion^ 
with  an  extravasation  of  blood  into  the  periosteum  and  bruising  of  the 
bone  substance.  Sometimes  hollows  or  depressions,  together  with  fis- 
sures, are  formed  in  the  bone  against  which  the  bullet  is  flattened  out, 
or  the  latter  is  found  impacted,  being  in  some  cases  split  in  two  and 
seated  astride  of  the  broken  edge  of  a  fragment  (Fig.  39S). 

In  rare  instances  a  gunshot  fracture  takes  place  not  directly  at  the 
point  where  the  bullet  strikes  the  bone,  but  at  some  distance  from  it, 
and  either  exists  by  itself  or  is  combined  with  a  fracture  at  the  point 
where  the  bullet  struck  (Lacronique).  These  indirect  gunshot  fractures 
mav  result  from  a  bend,  a  twist,  or  concussion  of  the  bone  in  question, 
and  occasionally  l>y  a  union  of  several  of  the  fissures  which  radiate  from 
the  point  where  the  bone  has  been  struck  by  the  bullet. 

Gunshot  injuries  of  joints  are  in  the  main  complicated  wounds  with 
or  without  injury  of  bone.  The  most  severe  gunshot  injuries  of  the 
joints  are  those  with  splintering  of  the  articular  ends  of  the  bones. 

The  Effects  produced  by  Modem  Projectiles, — Bush,  Kocher  and  others 
have  made  some  interestiug-  experiments  pertaining  to  the  action  of  projec- 
tiles consti'ucted  of  lead  and  the  kind  of  damage  they  cau>se  in  the  tissues; 
and  Reger  has  recently  studied  the  action  of  such  projectiles  upon  bone,  and 
has  come  to  some  practically  important  conclusions.  In  the  case  of  injuries 
made  by  soft  lead  within  a  range  of  four  hundred  metres,  an  effect  is  pro- 
duced which  is  like  an  explosion ;  the  wound  is  funnel-shai^ed,  and  the  bone 
is  crushed  to  fragments,  which  penetrate  the  soft  parts  posteriorly,  making 
the  opening  where  the  projectile  emerges  ten  to  twenty  times  as  large  as  the 
opening  where  it  entered.  In  the  case  of  gunshot  wounds  made  at  a  range 
of  five  hundred  to  one  thousand  metres,  a  clean-cut,  penetrating  wound  is 
made,  with  or  without  radiating  fissures.  If  the  projectile  traverses  the  lon- 
gitudinal axis  of  the  hone,  extensive  splintering  of  the  latter  may  be  pro- 
duced. In  the  case  of  wounds  made  at  a  range  of  one  thousand  to  fifteen 
hundred  metres,  comminuted  fractures  with  considerable  shattering  of  bone 
not  infrequently  occur  in  spite  of  the  diminished  momentum  of  the  projec- 
tile. At  longer  ranges  there  is  a  slight  splintering  or  contu-sion  of  the  bone, 
in  which  the  bullet  will  often  be  found  impacted  CFig.  398). 

The  Action  of  Projectiles  of  Small  Calibre  (Eight  Millimetres  in  Diameter) 
with  a  Steel  Coating.— Chauvel,  Bovet  and  others  have  made  experiments 
with  the  new  small  calibre  feight  millimetres  in  diameter)  projectiles  covered 
with  nickel  or  steel,  which  have  lately  l^een  introduced  into  the  European 
armies.  All  the  experiments  show  that  these  new  projectiles  have  a  great 
penetrating  power  on  account  of  their  tremendous  velocity,  and  this  has  been 
still  further  increased  by  the  use  of  the  new  smokeless  powder.  The  projec- 
tiles which  are  coated  with  steel  retain  their  shape,  while  those  made  of  lead 
become  flattened  on  account  of  their  comparative  softness,  and  when  dis- 


gl34.] 


GUNSHOT   INJURIES. 


731 


Fig.  398. — Iinjjaction  and  Bplittintr  of  Icj 
bullets  ill  bone  (Ber;L,Miiannj. 


charged  at  a  short  range  show  a  considerable  explosive  effect.  At  shorl 
ranges,  however,  the  action  of  the  i)rojectiles  whicli  are  covered  with  .steel 
and  those  made  entire!}'  of  lead  is  very 
niiu'h  the  same,  except  that  the  penetrat- 
ing power  of  the  former  is  greater,  being 
sulHcient  to  pass  through  several  cada- 
vers placed  one  behind  the  other.  Ac- 
cording t«j  Bruns,  these  steel-coated  pro- 
jectiles can  i)ass  through  iron  plates 
twelve  millimetres  in  thickness,  or  pine 
wood  one  hundred  and  ten  centimetres 
thick,  at  a  range  of  twelve  metres.  At 
a  range  of  four  hundred  metres  Bruns  found  that  they  produced  an  effect 
like  an  explosion  upon  the  skull  only,  the  long  hollow  bones  not  suffer- 
ing such  extensive  injury;  at  a  range  of  eight  hundred  metres  perforating 
wounds  occurred  ;  and  even  at  a  range  of  twelve  hundred  metres  two  or 
three  parts  of  a  body  placed  one  behind  the  other  wei'e  completely  shot 
through.  The  projectiles  rarely  remain  in  the  body,  as  Hobart  and  Chauvel 
have  noted  by  experiments  made  at  ranges  as  long  as  fifteen  hundred  to  two 
thousand  metres.  In  general,  the  modern  projectiles  of  small  calibre  which 
are  covered  with  steel  are  more  humane  than  those  made  entu*ely  of  lead, 
and,  except  at  the  ranges  where  explosion  of  the  projectile  takes  place,  the 
wounds  thej'  make  have  a  more  favourable  prognosis,  since  the  bullets  do  not 
become  shattered,  but  make  a  smooth  puncture  with  small  openings.  The 
firearm  of  small  calibre  is  the  most  powerful  weai^on  of  modern  times,  on 
account  of  its  great  velocity,  long  range,  and  tremendous  penetrating  power. 
The  observations  made  upon  living  men  with  projectiles  of  eight  millime- 
tres diameter  correspond  very  closely  with,  those  mentioned  above  (Stitt). 
Up  to  certain  ranges  (twelve  hundred  to  two  thousand  metres)  projectiles 
which  strike  the  body  directly  pass  entirely  through  it,  forming  small  open- 
ings at  their  points  of  entrance  and  exit;  but  if,  before  entering  the  body, 
they  rebound  from  a  rock  or  piece  of  ii'on,  they  rarely  do  this.  In  these 
rebounding  shots  the  steel-covered  bullets  lose  their  shape  and  become  bent, 
the  steel  covering  bursts,  etc.,  and.  accordingly,  the  wounds  they  make  are 
torn  and  mangled,  and  the  openings  they  form  on  entering  and  coming  out 
are  much  larger. 

The  Course  of  Gunshot  Wounds. — The  course  of  gunshot  wounds  may 
be  inferred  from  what  we  have  already  said  of  injuries  to  the  soft  parts, 
bones,  and  joints,  and  the  reader  is  referred  to  tlie  paragraphs  which 
treat  of  these  subjects.  The  pain- is  usually  trifling,  as  the  wound  is 
made  so  quickly,  and  often  a  person  does  not  know  that  he  has  been 
hurt  until  lie  notices  tlie  blood.  The  haemorrhage  may  be  very  slight 
even  wlien  large,  deep-seated  arteries  have  been  injured,  and  it  ceases 
spontaneously  by  the  formation  of  a  thrombus  and  by  the  pressure  of 
the  surrounding  parts.  In  other  cases  the  wounded  person  dies  in  a 
few  minutes,  or  even  sooner,  if  a  large  artery  such  as  the  femoral  or 
the  carotid  has  been  divided. 


732  INJURIES  AND  DISEASES  OF  JOINTS. 

The  subsequent  course  of  a  gunshot  wound  depends  upon  whether, 
at  tlie  time  of  the  injury  or  afterwards,  infectious  substances  (bacteria) 
have  gained  access  to  the  wound  by  means  of  dirt  of  various  kinds, 
pieces  of  clotliing,  or  unclean  lingers,  instruments,  etc.  The  tempera- 
ture of  the  projectile  at  the  moment  when  it  struck  the  body  is  another 
matter  which  has  an  important  bearing  upon  the  course  of  the  wound, 
as  the  micro-organisms  are  often  killed  by  the  heat  of  the  ball,  espe- 
cially if  it  is  of  small  calibre  and  has  a  nickel  or  steel  covering.  Hence 
infection  of  gunshot  wounds  on  the  battle-iield  is  almost  always  due  to 
the  fact  that  innnediately  after  the  injury,  or  not  until  later,  micro- 
organisms gain  access  with  the  dirt,  or  from  insufiiciently  disinfected 
fingers  and  instruments.  This  infection  may  give  rise  to  the  various 
diseases  of  wounds,  such  as  progressive  inflammation  and  suppuration, 
sepsis,  and  pysemia.  Tetanus  is  also  not  infrequently  observed,  espe- 
cially if  earthy  materials  have  come  in  contact  with  the  wound.  If, 
however,  infection  does  not  take  place,  even  very  extensive  injuries  to 
bones  and  joints  heal  readily. 

Gunshot  wounds  inflicted  at  a  short  range,  in  which  both  soft  parts 
and  bone  are  badly  mangled,  have  the  worst  prognosis,  and  in  many 
cases,  especially  in  wounds  involving  the  trunk,  head,  or  abdomen, 
death  is  instantaneous.  If  a  patient  with  a  gunshot  wound  of  an  ex- 
tremity remains  alive,  a  conservative  plan  of  treatment  is  usually  hope 
less,  and  amputation  or  disarticulation  is  indicated.  It  has  alread_y 
been  remarked  that  the  modern  steel-coated  projectile  of  small  calibre, 
in  spite  of  its  great  penetrating  power — leaving  out  of  consideration 
the  range  within  which  it  explodes — makes  a  cleaner  wound  than  the 
old-fashioned  soft  lead  projectile,  which  mangles  and  lacerates  both 
bone  and  soft  parts. 

Treatment  of  Gunshot  Wounds. — Gunshot  wounds  are  treated,  in 
general,  according  to  the  same  principles  which  we  have  already  given 
for  the  treatment  of  injuries  to  the  soft  parts,  bones,  and  joints. 
Nevertheless,  I  shall  discuss  the  treatment  of  gunshot  wounds  some- 
what more  at  length,  with  particular  reference  to  their  treatment  in 
times  of  war.  For  the  special  treatment  of  penetrating  wounds  of  the 
head,  thorax  and  abdomen  the  reader  is  referred  to  the  Special  Sur- 
gery. 

We  think  with  a  shudder  of  that  period  of  the  middle  ages  when 
gunshot  wounds  were  wrongly  looked  upon  as  poisoned  wounds,  and 
were  therefore  burned  out  with  boiling  oil  in  order  to  destroy  the 
venom  of  the  powder.  Ambroise  Pare  and  Maggi  successfully  com- 
bated this  method  of  treatment  in  1551  and  1552.  The  story  is  told 
that  when  the  armv  of  King  Francis  of  France  stormed  the  little  castle 


t<  124.]  GUNSHOT   IN.IlTlilKS.  733 

of  \'illiino,  iiciir  Siisa,  Atnbroise  P.uv  did  not  have  sufficient  liot  oil  at 
hand  to  burn  out  all  the  j^unshot  injuries  in  accordance  with  the  treat- 
ment then  in  voi>iie.  On  the  next  day  all  those  wounds  which  had  not 
been  burned  out  with  oil  were  free  from  pain  and  intlaniniatory  swell- 
ing, while  those  which  had  been  thus  treated  were  very  painful  and 
much  swollen.  After  this  experience  ]*are  always  denounced  this 
cruel  method. 

Every  gunshot  injury  should,  of  course,  be  treated  according  to 
antiseptic  princij)les,  although  this  is  quite  a  different  thing  in  times  of 
peace  from  what  it  is  in  war,  when,  on  acconnt  of  the  great  numbers 
of  the  wounded,  it  is  not  possible  to  attend  to  every  case  as  carefully 
as  we  are  ordinarily  accustomed  to.  It  is  hence  very  natural  that  the 
expectant  treatment  of  gunshot  injuries  has  again  been  recommended 
for  military  practice. 

It  is  especially  important  to  check  the  haemorrhage  and  remove 
all  foreign  bodies  that  may  have  gotten  into  the  wound,  such  as  bullets, 
unclean  pieces  of  clothing,  etc.  But  it  is  a  bad  plan  to  hunt  for  the 
bullet  too  industriously  or  too  long,  as  they  subsequently  become  healed 
up  in  the  tissues,  just  like  other  foreign  bodies.  Dementjew  and  Berg- 
mann  saw  in  the  Russo-Turkish  AYar  eighteen  cases  in  which  the  ball 
healed  up  within  the  knee  joint.  Subsequently  the  projectiles  some- 
times leave  their  original  position  and  wander  about,  like  needles  or 
other  similar  bodies.  Bergmann  and  Reyher  made  very  successful  use 
of  the  expectant  treatment  during  the  Russo-Turkish  War,  even  in  cases 
of  injuries  involving  joints.  They  confined  themselves  to  a  disinfec- 
tion of  the  wound  and  its  neighbourhood,  and  then  immobilised  the 
extremity  in  plaster  of  Paris  with  or  without  an  antiseptic  occlusive 
dressing.  The  parts  often  united  per  pi^imaiii  intention  em,  the  bullet 
becoming  enclosed,  while  in  other  instances  suppuration  took  place,  and 
yet  the  bullet  remained  where  it  was.  The  expectant  plan  of  treat- 
ment may  be  accompanied  by  dangers  when  there  are  pieces  of  cloth- 
ing in  the  wound ;  but  these  form  the  minority  of  cases,  and  there  are 
usually  no  such  sources  of  infection  present.  If  one  decides  to  adopt 
operative  measures  and  enlarge  the  wound,  in  order  to  check  haemor- 
rhage, for  example,  or  on  account  of  inflammation  or  suppuration,  one 
must,  of  course,  proceed  according  to  general  antiseptic  principles. 
In  civil  practice  one  will  not  make  so  much  use  of  the  expectant  form 
of  treatment  for  gunshot  fractures,  but  will  follow  the  ordinary  rules 
which  govern  the  management  of  compound  fractures.  In  cases  of 
wounds  inflicted  at  short  ranges  with  extensive  mangling  of  the  soft 
parts  and  bone,  conservative  treatment  is  usually  hopeless,  and  ampu- 
tation is  in  general  indicated  ;  while  for  wounds  inflicted  at  long  ranges 


734  INJURIES  AND  DISEASES  OF  JOINTS. 

the  conservative  inetliod  should  first  be  tried,  as  it  is  in  such  cases  that 
it  has  been  shown  to  be  most  useful 

It  is  especially  important  that  the  wound  should  not  be  examined 
with  fingers  or  instruments  which  have  not  been  disinfected,  except, 
perhaps,  in  the  face  of  serious  hgemorrhage  which  threatens  the  pa- 
tient's life.  Many  a  wounded  person  has  lost  his  life  through  exam- 
ination of  his  injury  with  a  finger  or  a  probe  which  had  not  been 
properly  disinfected.  Keyher  is  right  in  discriminating  between  "fin- 
gered" wounds — i.  e.,  those  which  have  already  been  examined  by  a 
physician — and  "  unfingered  "  wounds— i.e..  those  which  come  directly 
under  the  surgeon's  care.  Out  of  eight  patients  with  '"  lingered  "  in- 
juries of  the  knee,  six  died  and  one  was  in  great  peril,  while  of  seven 
"unfingered  "  injuries  of  the  knee  six  recovered. 

The  primary  antiseptic  treatment  consists  either  of  antiseptic  occlu- 
sion of  the  wound  in  the  skin  or  antiseptic  drainage.  In  the  former — 
i.  e.,  in  healing  under  a  scab — all  exploration  of  the  wound  with  a  probe 
or  the  finger  sliould  as  far  as  possible  be  avoided.  If,  however,  an  ex- 
ploration of  the  wound  is  absolutel}^  necessary  on  account  of  dangerous 
hsemorrhage,  infection  of  the  wound,  etc.,  drainage  must  at  the  same 
time  be  provided  for,  and  any  operative  measures  which  may  be  neces- 
sary, such  as  removal  of  splinters  of  bone,  resection,  or  amputation, 
must  be  undertaken  at  once.  An  excellent  method  of  drainagre  in  case 
of  large  gunshot  wounds  is  to  pack  the  latter  with  iodoform  gauze  or 
sterilised  mull  ;  the  best  antiseptic  for  military  practice  is  probably 
bichloride  of  mercury.  The  drainage  should  i)e  as  simple  as  possible. 
It  has  been  suggested  that  each  soldier  be  supplied  with  the  material 
for  the  first  dressing  in  the  form  of  a  small  bundle  which  can  be  sewed 
into  his  coat  or  carried  in  the  breast  pocket  or  knapsack,  and  that  he 
should  also  liave  with  him  some  antiseptic  powder,  such  as  iodoform. 
I  think  this  plan  of  letting  each  soldier  apply  the  first  dressing  with  the 
materials  which  he  carries  with  him  is  a  bad  one.  since  these  dressinofs 
are  anything  but  antiseptic— in  fact,  they  are  usually  full  of  dirt.  It  is 
much  better  that  there  should  be  a  large  number  of  surgeons  and  well- 
trained  as.sistants  upon  the  field  furnished  with  sufficient  antiseptic  dress- 
ing materials,  and  that  the  dressings  which  the  soldiers  carry  with  them 
should  only  be  used  in  an  emergency.  These  consist  of  two  pieces  of 
compress  impregnated  with  bichloride,  one  bandage,  a  safety  pin,  and 
a  three-cornered  piece  of  cloth,  all  of  which  are  wrapped  up  in  some 
rubber  material.  In  order  that  antisepsis  may  be  properly  observed  in 
time  of  war  all  persons  entrusted  with  the  care  of  the  wounded  should 
be  previously  instructed  in  the  general  principles  of  antiseptic  treatment 
and  in  the  technique  of  applying  simple  antiseptic  dressings.    The  vol- 


^  r,M.]  GUNSHOT   INJURIES.  735 

untary  assistance  of  persons  in  the  liij^lier  walks  of  life,  especially  stu- 
dents, is  very  desirable  in  this  connection. 

The  sterilisation  of  dressings  can  be  carried  out  in  times  of  \s-ar  ac- 
cording to  the  same  principles  as  in  times  of  peace,  and  hence  it  is  not 
a  good  plan  to  make  a  collection  beforehand  of  dressing  materials  which 
have  been  impregnated  with  antiseptics,  as  they  will  be  subsequently 
found  to  contain  bacteria  in  spite  of  the  best  of  packing.  The  most 
suital)le  kind  of  dressings  are  those  which  can  be  ti-ansported  in  the 
smallest  possible  bulk,  such  as  mull,  hemp,  and  cotton.  The  conmion 
salt-bichloride  tablets  which  Angerer  has  recently  recommended  for 
military  practice  are  very  useful,  and  greatly  facilitate  the  preparation 
of  permanent  bichloride  solutions.  Instead  of  sponges,  aseptic  gauze 
pads  impregnated  with  bichloride  of  mercurj'  may  be  used. 

On  the  battle-field  the  wounded  are  first  carried  to  a  protected  spot, 
marked  by  a  white  flag  with  a  red  cross,  where  temporary  dressings  are 
applied,  so  that  they  can  be  transported  to  the  field  hospital  situated  near 
by.  At  the  first  place  only  the  operations  necessary  to  save  life  should 
be  performed,  such  as  arrest  of  hgemorrhage  and  amputation.  The  most 
seriously  wounded,  especially  tliose  who  cannot  get  to  this  place  by 
themselves,  should  be  attended  to  first.  In  future  battles  the  dispro- 
portion between  the  number  of  the  injured  and  tliat  of  the  surgeons 
will  be  even  more  evident  than  it  has  been  in  the  past,  as  the  rapid- 
firing  guns  now  used,  on  account  of  the  greater  accuracy  of  their  aim. 
will  probably  increase  the  numbers  of  the  wounded,  while  the  number 
of  surgeons  will  remain  about  the  same.  Hence  only  those  operations 
will  be  performed  which  are  absolutely  necessary.  Billroth  likewise 
expressed  the  fear  that  the  number  of  wounded  in  coming  battles  will 
be  so  great  that  there  will  not  be  sufficient  help  at  hand  to  render  them 
the  necessary  assistance  while  the  battle  is  going  on.  Ilaase  states  that 
the  organisation  for  the  care  of  the  wounded  which  the  German  army 
possesses  will  amount  in  future  wars  to  forty-five  thousand  well-trained 
men  (hospital  orderlies,  carriers  of  the  wounded,  etc.).  Thus  we  can 
see  that  a  liberal  provision  has  been  made.  At  the  field  hospitals, 
which  are  usually  churches,  school-houses,  or  other  large  buildings,  or 
tents  and  barracks,  the  wounded  who  are  brought  in  with  temporary 
dressings  on  are  examined  with  antiseptic  precautions  and  permanent 
dressings  then  applied,  and.  when  necessary,  the  wounds  are  enlarged, 
drained,  and  disinfected.  Those  who  have  thus  been  dressed  antisep- 
tically  are  then  transported  to  a  permanent  hospital.  During  trans- 
portation injured  portions  of  the  body,  especially  gunshot  fractures, 
must  be  immobilised  as  thoroughly  as  possible  (see  ^  53  and  page  219). 

In  addition  to  tents.  Dockers  barracks  are  particularly  well  adapted 


736 


INJURIES  AND   DISEASES   OF  JOINTS. 


for  quarters  for  the  wounded.  Haase  states  that  an  army  of  100,000 
men  need  601  movable  and  167  stationary  barracks  to  furnish  room  for 
from  15,0U0  to  18,000  wounded.  Some  of  the  barracks  used  for  war 
purposes  are  made  of  felt  (Docker's  barracks),  while  others  are  tents  or 
wooden  sheds.  Ilaase  is  riglit  in  recommending  tliat  these  tents  and 
barracks  be  put  in  position  by  bodies  of  men  organised  for  that  purpose 
and  under  the  command  of  special  officers. 

We  have  not  space  to  take  up  more  in  detail  the  first  treatment  of 
the  wounded  on  the  battlefield,  but  whoever  is  interested  in  this  subject 
should  consult  the  books  which  have  been  written  upon  it  by  Esmarch 
and  Port.     A  very  excellent  and  exhaustive  treatise  on  military  surgery 
will  be  found  in  Fischer's  Handbuch  der  Kriegschirurgie 
(Deutsche  Chirurgie,  Stuttgart,  1882).     For  a  descrip- 
tion of  the  easily  transportable  operating  table  which  I 
liave  devised  for  military  practice,  see  page  7,  Figs. 
4  to  6. 

Search  for  a  Ball. — In  searching  for  a  ball  one  may  use 
the  finger  or  an  ordinary  probe,  and  in  the  case  of  very  deep 
wounds,  long,  curved  or  straight  dressing  forceps,  silver 
catheters,  etc.  Graham  Bell  has  invented  an  electric  probe 
for  finding  bullets.  A  needle  which  has  been  insulated  by 
coating  all  but  its  point  with  varnish  is  inserted  into  ibe 
region  where  the  presence  of  the  projectile  is  suspected  and 
then  connected  with  the  end  of  a  telephone  wire.  A  metallic 
plate  of  the  same  material  as  the  needle  is  fastened  to  tbe 
end  of  the  other  wire  and  applied  to  the  skin  in  the  neigh- 
bourhood of  the  bullet.  If  the  point  of  the  needle  comes  in 
contact  with  the  ball  the  circuit  is  closed,  and  every  time 
they  come  together  a  distinct  noise  is  heard  in  the  telephone. 
Klein  has  coustructed  a  similar  electro-microphonic  searcher 
(see  Aerztl.  Polytechnik,  March,  1892j.  The  magnetic  needle 
can  also  be  used  in  suitable  cases  for  finding  a  ball  even 
after  it  has  become  healed  up  in  the  tissues,  and  is  especially 
apj)licable  to  the  search  for  the  modern  steel-coated  projec- 
tiles. Gartner  recommends  that  the  steel-covered  bullet 
which  has  entered  the  body  be  first  magnetised  by  stroking 
the  area  in  question  with  a  powerful  magnet.  By  means  of 
a  sensitive  magnetic  needle— i.  e.,  a  pair  of  astatic  needles  suspended  by  a 
silk  thread,  or  Lamont's  magnetoscope — the  point  on  the  skin  is  determined 
to  which  the  ball  or  iron  splinter  lies  nearest  (Kocher,  Gartner,  Sachs). 
Gartner  constructed  an  astatic  magnetic  needle  out  of  a  magnetised  sewing 
needle  which  he  broke  in  two,  a  straw,  and  a  piece  of  silk  thread,  and  made 
successful  use  of  it  in  finding  projectiles  after  having  first  magnetised  them. 
The  old-fashioned  probe  invented  by  Nelaton  has  a  knob  made  of  porcelain 
which  is  made  black  by  contact  with  the  bullet. 

Projectiles  are  extracted  by  means  of  forceps,  or  spoon-shaped  instru- 


Fio.  399.— Ameri- 
can forceps  for 
extracting  a  l^ul- 
let. 


g  124.]  GUNSHOT   INJURIES.  737 

ments.  The  most  simple  kind  are  tlie  long,  curved  or  straight  dressing 
foi'ceps,  or  long,  narrow  forceps  with  sharp-pointed  teeth  which  cover  one 
another  when  closed  (Fig.  31).'?),  so  that  they  do  not  injure  the  tissues  but  be- 
come inserted  into  the  lead  when  they  seize  the  ball.  The  best-known 
spoon-shaped  instruments  are  Thomassin's  and  Langenbeck's.  Elevators 
can  also  be  employed  for  this  purpose.  Formerly,  if  the  ball  wei'e  firmly  em- 
bedded in  the  bone,  it  was  extracted  by  screws  or  augers,  which  were  bored 
into  the  lead  like  corkscrews.  These  augers  and  screws,  and  the  forceps 
with  the  sharp-pointed  teeth,  are  uo  longer  used  for  the  modern  steel-coated 
projectiles,  having  been  superseded  by  narrow,  straight,  or  curved  forceps. 
The  steel  covered  projectiles;  however,  remain  lodged  in  the  body  much 
more  rarely  than  the  lead  bullets;  they  usually  pass  entirely  through  it  and 
emerge  externally. 


47 


CHAPTER  Y. 


TUMOURS. 


Tumours  in  general. — Definition  and  classification  of  tumours. — Etiology  of  tu- 
mours. —  Clinical  features,  diagnosis,  prognosis,  and  treatment. — The  ana- 
tomical structure  and  clinical  course  of  the  different  varieties  of  tumours,  with 
their  treatment. 

'  §  125.  Tumours  in  General — Definition  and  Classification. — The 
study  of  tumours  forms  one  of  the  most  interesting  cliapters  of 
pathology ;  but  it  would  require  too  much  space  to  discuss  this  vast 
subject  with  anything  like  completeness,  and  so  we  must  satisfy  our- 
selves with  merely  a  superficial  account  of  such  tumours  and  growths 
as  are  amenable  to  surgical  treatment.  I  must  refer  the  reader  to  the 
excellent  text-books  of  Yirchow,  Waldeyer,  Cohnheim  and  others  for 
a  description  of  the  general  pathology  and  anatomy  of  neoplasms. 

The  question,  What  is  a  tumour?  has  received  various  answers. 
In  fact,  it  is  difficult  to  give  a  suitable  definition  which  includes  all 
tumours,  as  they  present  marked  differences  anatomically,  etiologically, 
and  clinically.  Liicke's  definition  has  been  the  most  widely  accepted. 
According  to  him,  we  mean  by  a  tumour  an  increase  in  the  volume  of 
some  portion  of  the  body,  due  to  a  new  formation  of  tissue  which 
reaches  no  physiological  limit,  and  which — to  add  Cohnheim's  words — 
differs  from  the  morphologico-anatomical  type  of  the  locality  where  it 
occurs.  "\Ve  distinguish  from  true  tumours  the  hyperplastic,  inflam- 
matory formations,  all  the  infectious  granulation  tumours  of  tubercu- 
losis, syphilis,  leprosy,  etc.,  and  certain  collections  of  fluid  and  cells  in 
preformed  cavities,  such  as  aneurysm,  hygroma  of  tendon  sheaths  and 
mucous  bursae,  hydrocele  of  the  tunica  vaginalis  testis,  and  all  reten- 
tion cysts.     We  recognise,  as  Cohnheim  does : 

1.  Tumours  the  main  portion  of  which  is  of  the  connective-tissue 
type ;  these  include  fibroma,  lipoma,  myxoma,  chondroma,  osteoma, 
angeioma,  Ivmphangeioma,  endothelioma,  lymphoma,  and  sarcoma, 
together  with  mixed  or  combination  tumours  made  up  of  simpler 
forms. 

2.  Tumours  having  the  type  of  muscular  tissue  :  Myoma  laevicellu- 
lare  and  myoma  striocellulare. 

(738) 


§126.]  ETIOLOGY   OF  TUxMOURS.  739 

3.  Tumours  made  u[)  of  nerve  tissue  :  Neuroma  and  glioma. 

4.  Tumours  of  the  epithelial  tjj^e — viz.,  epitlielioma,  onychoma, 
adenoma,  cystoma,  and  carcinoma.  There  remains  as  a  subdivision  of 
this  group  the  teratoma  of  Virchow,  in  which  many  different  kinds  of 
tissue — such  as  hair,  skin,  bone,  teeth,  parts  of  intestine  and  brain — are 
found.     In  this  class  belong  the  dermoid  cysts. 

Birch-llirschfeld  makes  the  following  qlassiHcation  :  1.  Connective- 
tissue  tumours;  2,  muscle  tumours;  3,  nerve  tumours;  4,  epithelial 
tumours ;  5,  mixed  or  combination  forms  of  tumours ;  6,  cystic 
tumours,  consisting  of  a  closed  sac  containing  more  or  less  fluid.  This 
group  includes  tumours  which  are  etiologically  and  histologically  very 
different ;  some  of  them  (retention  cysts)  do  not  belong  to  the  ])rolifer- 
ating  tumours  at  all,  while  others  are  due  to  abnormities  of  develop- 
ment (teratoma-dermoid  cysts),  or  originate  secondarily  from  different 
tumours  (cystoma  glandulare,  cystosarcoma).  7.  Infectious  tumours 
(granulation  tumours)  which  are  related  histologically  and  etiologically 
to  the  inflammatory  formations,  and  do  not  belong  amongst  the  true 
tumours  (products  of  tuberculosis,  syphilis,  leprosy,  etc.). 

§  126.  Etiology  of  Tumours. — The  etiology  of  tumours,  meaning 
thereby  neoplasms,  still  remains  obscure,  although  many  theories  have 
been  advanced  upon  this  subject.  Their  causes  are'partly  direct  and 
partly  indirect  or  predisposing,  the  latter  including  the  effects  of  age, 
sex,  occupation,  etc.  Esmarch  thinks  that  inherited  predisposition 
plajs  an  important  part  in  their  causation,  and  in  many  cases — notably 
of  sarcomata — he  l)elieves  that  their  development  depends  upon  a  pre- 
disposition inherited  from  syphilitic  ancestors.  As  direct  causes  of 
tumours,  local  irritations — mechanical,  chemical,  or  inflammatory  in 
nature — have  been  thought  especially  important.  Thus  we  know  that  a 
sarcoma,  for  instance,  occasionally  forms  after  a  severe  contusion,  or 
that  an  epithelioma  of  the  lower  lip  or  of  the  mucous  membrane  of 
the  mouth  develops  in  immoderate  smokers,  or  as  ^  result  of  frequently 
repeated  traumatic  irritations  caused  by  a  sharp  tooth,  frequent  shav- 
ing with  dull  razors,  etc.  A  similar  explanation  is  given  for  the  origin 
of  the  epithelioma  which  is  met  Avith  upon  the  scrotum  of  chimney 
sweeps  and  people  employed  in  the  manufacture  of  tar  and  paraflin. 
Sometimes  after  fractures  benign  (osteoma,  chondroma)  and  malignant 
tumours  (sarcoma)  develop  in  the  callus^ — the  so-called  callus  tumours. 
According  to  Rapok,  one  hundred  and  twenty-eight  out  of  six  hundred 
and  sixty-nine  tumours  followed  injuries.  But  the  number  due  to 
this  cause  alone  is,  as  Ball  and  Winiwarter  state,  not  large,  nor  is 
mechanical  or  chemical  irritation  sufficient  in  itself  to  produce  one  ; 
first  of  all  there  must  be  present  a  predisposition  of  the  part  in  ques- 


/j'40  TUMOURS. 

tion  to  the  development  of  a  tumour,  and  it  is  this  that  is  really  the 
^,  determining  cause  of  tumour  formation.  Sometimes  disturbances  of 
the  nervous  system — trophoneuroses — play  an  important  part  in  their 
causation.  Buchterkirch  and  Bumke  saw  a  case  of  multiple,  sym- 
metrical lipomata  which  followed  a  contusion  of  the  spinal  cord. 
A  preceding  inflammation  has  a  very  important  influence  upon  the 
development  of  neoplasms,  as  is  shown  in  those  cases  of  carcinoma 
of  the  breast  which  follow  a  mastitis.  Malignant  tumours,  both 
carcinoma  and  sarcoma,  often  originate  from  simple  warts,  and  me- 
lanomata  from  small  patches  of  pigment  in  the  skin.  Rapok  states 
that  one  hundred  and  eighty-two  out  of  three  hundred  and  ninety- 
nine  carcinomata  started  in  warts,  and  indeed  one  third  of  all  the 
instances  of  tumours  collected  by  him  (six  hundred  and  ninety-nine) 

<>''  had  this  origin.  According  to  Woodhead,  tumours  are  dueto  a  de- 
ficiency—  not  a  superfluity  —  of  nourishment;  even  though  there  is 
actually  an  increased  amount  of  food  taken  into  the  system,  this  is 
not  able  to  supply  the  needs  of  the  tissues  in  question.  He  holds  the 
view  that  tumours  develop  when,  as  a  result  of  irritations  from  dif- 
ferent sources — such  as  injuries,  parasites,  microbes,  long-continued 
action  of  an  irritating  organic  or  inorganic  substance,  or  a  simple 
chronic  catarrh — so  great  an  increase  in  the  activity  of  the  tissue  ele- 
ments is  demanded  that  the  food  brought  into  the  system  is  insufficient 

^  to  supply  these  demands.  Schleich  looks  upon  tumour-formation  as  a 
kind  of  infection  originating  within  the  organism,  a  cell  at  a  certain 
stage  of  its  physiological  development  becoming  infectious  as  a  result 
of  irritations  of  various  sorts.  Analogously  to  the  development  of  an 
impregnated  ovum,  tumours  are  considered  by  him  as  products  of  a 
pathological  conception  and  impregnation  ;  the  pathological  spermato- 
zoon is  represented  by  the  cell  that  has  become  infectious.  Many 
authorities  think  that  tumours  are  caused  by  micro-organisms,  and  we 
shall  consider  this  question  when  we  take  up  carcinomata. 

^  Cohnheim  developed  a  very  ingenious  theory  as  to  the  ultimate  cause 

of  new  growths.  He  thought  this  to  be  an  abnormity  or  irregularity 
in  the  embryonic  rudiment  of  the  part  of  the  body  in  question — in  short, 
\  that  neoplasms  originate  from  the  growth  of  embryonic  germs  or  ger- 

minal cells  which  have  been,  as  it  were,  shut  up  in  the  normal  tissues. 
In  many  individuals  these  tumour  germs  do  not  become  developed,  but 
in  others  traumatisms,  mechanical  and  chemical  irritation,  or  the  dimin- 
ished powers  of  resistance  possessed  by  the  surrounding  normal  parts, 
increased  blood  supply,  etc.,  may  arouse  them  to  activity.  This  theory 
of  Cohnheim's  seems  very  plausible  for  many  cases,  but  it  lacks  ana- 
tomical foundation  ;  in  fact,  as  Birch-Hirsclifeld  says,  a^sitive  pi-oof 


§  12GJ.  ETIOLOGY  OF  TUMOURS.  74I 

of  the  correctness  of  Colinheiin's  hypothesis,  as  appHed  to  tumours  in 
general,  is  (piite  inipossible.  It  is,  however,  miquestionable^tliat  some 
tumours  spring  from  embryonic  germs,  and  certain  facts  are  very  well 
explained  by  Cuhnheini's  theory — viz.,  the  transmission  of  tumours 
by  inheritance,  the  occurrence  of  congenital  tumours,  and  of  certain 
tumours  in  particular  portions  of  the  body,  such  as  epithelial  tumours, 
carcinomata  of  the  li]),  tongue,  cardiac  or  pyloric  orifices  of  the 
stomach,  glans  penis,  portio  vaginalis,  ceryicis,  etc. ;  in  other  words,  in 
localities  where  inversions  of  the  epiblast  in  the  form  of  groups  of 
epithelial  cells,  which  have  strayed  away  during  the  embryonic  period, 
may  easily  take  place.  Cohnheim's  hypothesis  also  furnishes  the  best 
means  of  explaining  the  heterologous  origin  of  primary  epithelial 
tumours  in  organs  which  do  not  contain  epithelium.  We  know,  for 
instance,  that  the  dermoid  cysts  are  a  result  of  stray  embryonic  germs. 
But  tumours  probably  do  not  have  an  unvarying  etiology.  As  Ziegler 
has  said,  new  growths  arise  from  different  tissues,  these  being  (1)  em- 
bryonic tissue,  (2)  growing  tissue,  (3)  fully  formed  tissue,  and  (4) 
tissue  in  the  stage  of  retrogression.  In  early  life,  connective-tissue 
tumours  predominate,  as  a  rule ;  iii_old  age  epitheliomata  and  carci- 
nomata. 

Transmissibility  of  Tumours. — Great  importance  attaches  to  the 
question  whether  or  not  tumours,  especially  malignant  ones  (carcinoma, 
sarcoma),  are  transmissible  in  the  sense  that  living  tumour-cells,  when 
transplanted,  can  give  rise  to  the  development  of  the  same  kind  of 
malignant  tumour  in  that  part  of  a  body  to  which  they  are  transferred. 
Such  a  transmissibility  of  tumours  has  in  fact  been  sufficiently  proved 
in  the  case  of  both  animals  and  man  by  experimental  and  clinical  obser- 
vations. Eiselsberg  successfully  inoculated  rats  with  a  fibro-sarcoma. 
In  regard  to  the  transmissibility  of  carcinoma  see  page  781  ;  of  mela- 
noma, page  770, 

Etiology  of  Tumours  in  Animals.— PI icque  has  published,  in  regard  to  the 
origin  of  tumours  in  animals,  some  interesting  facts  which  show  many  analo- 
gies to  tumour-formation  in  man.  The  real  cause  of  tumours  in  animals  is, 
to  be  sure,  unknown,  as  far  as  the  predisposition  of  the  bearer  is  concerned. 
But  as  regards  the  direct  cause,  the  following  has  been  noted  :  The  carcino- 
ma of  the  lip  in  horses  generally  develops  in  the  corners  of  the  mouth  from 
pressure  of  the  bit,  while  in  cats  the  upper  lip  is  ordinarily  affected  as  a  re- 
sult of  the  repeated  bites  of  small  animals.  The  subcutaneous  fibroma  which 
is  often  seen  in  horses  is  caused  by  the  pressure  of  the  harness.  Constant  or 
frequently  i^epeated  traumatisms  play  an  important  part  in  the  origin  of  tu- 
mours in  animals,  as  do  also  preceding  inflammations.  Bitches  suffer  from 
carcinoma  of  the  mammary  glands  much  oftener  than  male  dogs,  and  the 
hindermost  glands  are  the  ones  most  commonly  affected,  as  they  are  particu- 


742 


TUMOURS. 


larly  likely  to  be  the  seat  of  a  mastitis.  The  melanosis  of  horses  is  thought 
to  be  transmissible  by  inheritance,  so  that  mares  or  stallions  which  have 
it  cannot  be  used  for  breeding ;  heredity  is  also  said  to  play  a  part  in  the 
origin  of  the  mammary  cancer  of  bitches. 

The  influence  of  age  is  very  noticeable  in  animals.  In  old  dogs  carcino- 
ma is  very  frequent,  while  young  ones  are  practically  immune.  Whether 
the  nutrition  of  the  animal  plays  a  part  in  the  tumour-formation,  as  has  been 
thought  to  be  the  case  in  carcinoma  in  man,  cannot,  as  Plicque  says,  be  easily 
decided.  Amongst  pronounced  carnivora  like  the  dog.  carcinoma  is  very 
common,  and  herbivora  like  the  horse  are  not  exempt  when  they  reach  an 
advanced  age. 

§  127.  Growth,  Course,  Diagnosis,  and  Treatment  of  Tumours. — The 

growth  of  tumours  takes  place  in  exactly  the  same  way  as  that  of  other 
tissues — by  cell  proliferation.  The  rapidity  of  growth  is  very  variable, 
depending  upon  the  locality,  the  blood  supply,  and  the  structure  of  the 
tumour.  The  more  cells  the  latter  has,  the  iiiore  rapidly  it  grows. 
Localised  or  more  diffuse  disturbances  of  nutrition,  such  as  fatty  de- 
generation, calcification,  and  colloid  degeneration  or  necrosis,  resulting, 
perhaps,  in  a  complete  spontaneous  cure  of  the  tumour  very  frequently 
occur.  Necrosis  which  takes  the  form  of  ulceration  is  exceedingly 
common,  especially  in  carcinomata  which  have  broken  through  the 
skin  or  mucous  membrane.  According  to  Nepveu  and  Yerneuil,  the 
softening  of  tumours  is  caused  in  some  instances  by  bacteria.  A  true 
tumour  does  not  disappear  spontaneously ;  some  remain  stationary, 
while  others  keep  on  growing  at  a  faster  or  slower  rate.  The  most 
imjDortant  distinction  between  tumours  is  presented  by  their  clinical 
course,  and  this  allows  us  to  divide  them  into' benign  and  malignant 
growths.  The  former  remain  local,  but  the  latter  penetrate  into  the 
neighbouring  tissues  and  destroy  them,  and  the  tumour  germs,  being 
carried  off  in  the  blood  and  lymph,  give  rise  to  metastatic  or  secondary 
neoplasms  in  all  parts  of  the  system,  especially  the  liver  and  lungs. 
Carti[age  is  the  only  tissue  in  which,  so  far  as  I  know,  no  metastases 
have  been  found.  The  metastases  have  essentially  the  same  structure 
as  the  primary  tumours,  and  are  found  either  in  the  vicinity  of  the  lat- 
ter— that  is,  in  the  region  supplied  by  the  lymph  and  blood  which  come 
directly  from  the  tumour — or  in  distant  organs  after  the  tumour  germs 
have  passed  through  the  heart.  Metastases  due  to  capillary  emboli  are 
most  coujmonly  caused  by  the  tumour  cells  wliich  pass  through  the 
lungs  in  the  venous  blood  without  being  retained  there  (Zahn").  Should 
the  germs  be  carried  through  the  lymph  vessels,  they  usually  become 
implanted  in  the  nearest  lymph  glands  and  here  lead  to  the  develop- 
ment of  tumour  tissue  which  is  identical  with  that  of  the  original  neo- 
plasm.    In  this  way  the  infected  lymph  glands  become  new  foci  for 


§  137.]  GROWTH,  COURSE,  DIAGNOSIS,  TREATMENT   OF  TUMOURS.     743 

further  infection  and  development  of  metastases.  Tlie  tumour  germs 
also  enter  the  vascular  system  by  a  direct  ingrowth  of  the  mother 
tumour  into  the  walls  of  the  vessels.  I  once  saw  a  metastasis  in  a 
valve  of  the  femoral  vein  in  a  case  of  sarcoma  of  the  leg.  Tuinours 
which  in  other  respects  are  benign — such  as  fibroma,  lipoma,  cystic 
goitre,  chondroma,  myoma,  etc. — may  also,  in  exceptional  instances,  give 
rise  to  metastases.  It  is  characteristic  of  tumour  metastases — especially 
those  from  the  really  malignant  tumoui-s — to  go  on  growing  indefinitely. 
Normal  tissue  germs  do  not  have  this  peculiarity,  as  is  shown  by  the 
experiments  of  Cohnheim,  Maas,  etc.  Small  pieces  of  periosteum  and 
embryonic  cartilage  implanted  in  the  circulation,  the  peritoneal  cavity, 
or  in  the  anterior  chamber  of  the  eye,  grow  for  a  time  and  can  thus 
give  rise  to  very  small  osteomata  or  enchondromata  ;  but  these  soon 
disappear  without  leaving  any  traces.  If,  on  the  other  hand,  living 
tumour  cells  from  a  carcinoma  or  sarcoma,  for  example,  are  inoculated 
upon  animals,  they  go  on  developing,  and  give  rise  to  tumours  wdiich 
are  the  same  as  the  original  ones.  Man  also  may  become  infected 
with  the  germs  of  tumours,  and  this  has  occurred  during  operations 
for  their  extirpation.  Carcinoma  and  sarcoma  are  the  typical  malig- 
nant tumours  ;  they  lead  to  local  destruction  of  tissue  and  to  general 
infection  of  the  body  by  the  formation  of  metastases.  They  are  espe- 
cially the  ones  which  so  commonly  reappear  at  the  original  site  after  they 
have  been  extirpated.  These  recurrences  are,  according  to  ThierscK, 
due  partly  to  tumour  germs  which  were  not  removed,  though  in  other 
instances  we  have  to  deal  with  a  new  tumour — a  so-called 'regional  re- 
currence— similar  to  the  one  that  was  removed,  which  makes  its  ap- 
pearance in  the  cicatrix  or  near  by,  months  or  even  years  afterwards. 
Then,  again,  recurrences  may  be  due  to  the  inoculation  at  some 
point  of  living  tumour  cells  during  the  extirpation  of  the  primary 
tumour.  It  can  easily  be  understood  that  a  benign  tumour  may  also 
prove  fatal  to  the  bearer  on  account  of  its  position,  as  exemplified  by 
an  osteoma  on  the  inner  tablet  of  the  skull. 

The  evil  effects  of  tumours  upon  the  organism  are  partly  local  and 
partly  constitutional  in  character.  Those  in  particular  which  grow 
rapidly  are  a  great  drain  upon  the  system.  The  part  which  is  affected 
may  be  entirely  destroyed,  and  the  formation  of  metastases,  together 
with  the  necrosis  and  ulceration  undergone  by  the  tumour,  may  involve 
different  organs  and  eventually  lead  to  an  increasing  general  cachexia, 
to  which  the  patient  will  succumb.  This  cachexia,  manifesting  itself 
in  the  form  of  general  disturbances  of  nutrition,  loss  of  flesh,  and 
marasmus,  appears  in  malignant  tumours  which  are  accompanied  by 
local  destruction  of  tissue  and  metastases.     Rommelaire  and  Ranzier 


744  TUMOURS. 

have  found  that  the  excretion  of  urea  is  diminished  in  all  malignant 
tumours,  and  may  ultimately  become  less  than  twelve  grannnes  yro  die. 
The  degree  and  rapidity  of  development  of  the  cachexia  depends  upon 
the  location  of  the  tumour^its  condition  (ulceration,  necrosis,  hgemor- 
rhage),  and'the  age  and  constitution  of  the  patient.  The  malignancy  of 
the  infectious  tumours  varies  very  considerably.  Some,  like  epithelioma 
of  the  lip  and  the  Hat  skin  cancer  {xilcus  rodens),  spread  but  slowly  to 
the  nearest  l^'mph  glands,  while  others — carcinomata  and  sarcomata, 
for  instance — go  on  very  i-apidly  to  the  formation  of  metastases  in  in- 
ternal organs.  The  above-mentioned  gradual  diminution  in  the  excre- 
tion of  nitrogen,  which  is  met  with  in  malignant  tumours,  may  occa- 
sionally have  great  value  in  determining  the  need  and  prognosis  of 
surgical  interference,  especially  if  the  decrease  in  the  amount  of  urea 
is  marked,  in  which  case  operative  procedures  are  contraindicated.  i' 

The  Possibility  of  curing  Malignant  Tumours  {Carcinoma  and  Sar- 
coma).— A  variety  of  statements,  based  upon  statistics,  have  been  pub- 
lished relating  to  the  curability  of  the  malignant  tumours.  Fischer 
and  Meyer  have  written  an  especially  interesting  article  on  this  subject. 
Of  two  hundred  and  ninety-eight  cases  of  malignant  tumours  operated 
upon  by  Rose  in  the  hospital  at  Zurich  between  1867  and  1878,  Meyer 
was  able  to  get  reliable  returns  from  sixtj'-four.  Of  these  sixty-four, 
twenty-two  were  alive  in  1887  without  recurrence,  and  showed  a  period 
of  exemption  varying  from  nine  years  and  seven  months  to  twenty 
years  and  three  months.  Nineteen  died  without  recurrence,  the  period 
of  exemption  varying  from  one  and  a  half  to  sixteen  years.  In  the 
remaining  five  patients  the  cause  of  death  could  not  be  ascertained. 
Amongst  the  cases  of  cure  were  some  exceedingly  serious  ones,  involv- 
ing very  extensive  operations,  with  removal  of  recurrent  tumours  and 
diseased  lymphatic  glands.  Sarcoma,  cysto-sarcoma,  and  iibro-sarcoma 
showed  the  longest  period  of  exemption,  while  carcinoma  showed  the 
fewest  instances  of  permanent  cure.  In  rare  cases  of  sarcoma  of  the 
skin  and  multiple  melanosarcoma,  spontaneous  retrograde  changes 
have  been  observed  which  have  resulted  in  the  complete  and  perma- 
nent disappearance  of  the  tumours  (Hardaway). 

Diagnosis  of  Tumours. — The  diagnosis  of  tumours  is  not  always  easy. 
By  means  of  inspection,  palpation,  and  examination  of  the  subjective 
symptoms  we  try  to  form  as  correct  an  idea  as  possible  of  the  location 
and  structure  of  the  tumour.  The  location  of  a  neoplasm  often  enables 
us  to  determine  its  nature.  Very  often  a  differential  diagnosis  must 
be  made  between  an  inflammatory  process  and  a  new  growth  (see  page 
251,  Diagnosis  of  Inflammation).  In  doubtful  cases  puncture  with  a 
hypodermic  needle  may  be  necessary.     It  is  often  very  important  to 


§  127.]  GROWTH,  COURSE,  DIAGNOSIS,  TREATM^INT   OF  TUMOURS.     745 

determine  before  the  operation  whetlicr  the  tumour  i.s  benign  or  malig- 
nant, in  order  to  decide  upon  the  kind  of  operation  to  pursue.  In 
suitable  cases — for  example,  in  growths  within  the  larynx  probal)ly 
carcinomatous  in  nature — parts  of  the  tumour  are  removed  and  exam- 
ined microscopically.  Syphilis,  tuberculosis,  and  other  chronic  infec- 
tious diseases  must  always  be  considered  in  making  a  differential  diag- 
iiosis,  as  ajiu-ge  number  of  the  connective-tissue  tumours — such  as  cer- 
tain so-called  sarcomata  of  muscle,  many  spindle-celled  sarcomata, 
neuromata,  keloids,  and  malignant  lymphomata  (Esmarch) — are  gura- 
niata,  and  can  be  cured  by  an  antisy|)hilitic  treatment. 

General  Treatment  of  Tumours. — The  general  rule  in  regard  to  the 
treatment  of  tumours — which  we  shall  later  discuss  more  fully  in  speak- 
ing of  the  individual  tumours — is  that  they  should  be  removed  as  quickly 
and  as  thoroughly  as  possible.  The  sooner  a  malignant  tumour  is  radi- 
cally excised  the  better  is  the  prospect  of  a  complete  and  permanent 
cjire.  The  possibility  of  the  total  removal  of  a  tumour  depends  upon 
its  location  and  the  kind  of  organ  involved.  In^  malignant  tumours, 
especially  carcinoma,  the  neighbouring  lymph  glands  should  also  be  re- 
nioved,  even  though  they  are  not  diseased,  and  after  every  amjyutatio 
mammce  for  carcinoma  the  lymphatic  glands  and  surrounding  fat  in 
the  axilla  must  likewise  be  extirpated.  The  removal  of  tumours  is  ac- 
complished usually  by  the  knife,  though  occasionally  by  the  galvano-  or 
therm o-cautery,  red-hot  iron,  ligature,  ecrasement^  etc.,  methods  all 
of  which  have  been  sufficiently  described  in  §§  24—44. 

In  proper  cases  Pean  recommends  the  removal  of  the  tumour  in 
pieces  {morcellement).  The  method  consists  mainly  in  first  rendering 
the  tumour  as  bloodless  as  possible  by  the  use  of  differently  formed 
clamps  applied  around  its  circumference,  after  which  the  growth  is  ex- 
cised in  portions,  and,  if  possible,  the  wound  is  sutured  while  the  for- 
ceps afe  still  in  place.  The  latter  can  then  usually  be  taken  off  and  the 
wound  dressed.  In  other  cases  Pean  leaves  the  forceps  in  position  for 
twelve  to  forty-eight  hours.  An  almost  bloodless  operation  can  thus  be 
performed  even  in  the  case  of  very  vascular  tumours. 

The  encapsulated,  myelogenic,  giant-celled  sarcoma  of  bone  can  in 
suitable  cases  be  removed  by  cutting  away  only  the  anterior  half  of  the 
bony  capsule  by  means  of  the  chisel  and  hammer,  or  the  saw,  and  then 
carefully  scraping  out  the  tumour  mass  with  a  sharp  spoon.  Kussbaum 
has  lately  made  use  of  the  thermo-cautery  for  the  destruction  of  malig- 
nant tumours  like  cancers.  By  cjrcumcision  with  the  thermo-cautery 
in  cases  of  inoperable,  malignant  neoplasms,  the  patient  can  be  helped 
very  materially ;  the  growth  of  the  tumours  is  thus  diminished,  the 
pain  caused  to  disappear,  and  any  carcinomatous  ulcerations  are  im- 


746 


TUMOURS. 


proved  and  their  decomposition  checked.  In  cases  of  slonglnng,  in- 
operable carcinomata,  the  removal  of  the  softened  portions  with  the 
sharp  spoon  and  the  subsequent  application  of  the  tliermo-cauterj  give 
good  results. 

Many  attempts  have  been  made  to  destroy  tumours,  especially  in- 
operable sarcoma  and  carcinoma,  lymphoma  and  myoma,  by  means  of 
parenchymatous  injections  of  absolute  alcohol,  tincture  of  iodone,  ergot- 
ine,  acetic  acid,  nitrate  of  silver,  arsenic,  turpentine,  osmic  acid,  phos- 
phorus, etc.  Turpentine  is  injected  with  equal  parts  of  absolute  alco- 
hol, or  one  part  of  turpentine  to  two  parts  of  alcohol,  from  a  half  to  a 
whole  hypodermic  syringeful  about  every  ten  to  fourteen  days.  This 
is  usually  followed  by  the  formation  of  abscesses  which  cause  a  variable 
amount  of  shrinkage  in  the  size  of  the  tumour.  Some  three  drops  of 
a  one-per-cent.  solution  of  osmic  acid  is  injected  every  day.  Arsenic 
can  be  given  in  the  form  of  Fowler's  solution,  either  internally  or  sub- 
cutaneously.  Internally  one  begins  with  ten  di'ops  daily,  and  increases 
the  dose  two  to  three  drops  every  third  day.  About  two  drops  of 
Fowlers  solution,  undiluted,  are  injected  into  the  tumour  daily,  or  ten 
drops  of  the  undiluted  solution  once  a  week.  The  solution  may  be  di- 
luted two  or  three  times  for  susceptible  patients.  The  arsenic  treat- 
ment was  recommended  by  Billroth,  especially  for  malignant  lympho- 
ma. Mosetig-Moorhof  finds  the  parenchymatous  injection  of  aniline 
■dyes  (pyoktannin,  methyl  violet,  1  to  500)  very  useful  in  malignant  tu- 
mours (carcinoma  and  sarcoma),  but  the  success  which  he  has  reported 
has  not  been  experienced  by  other  surgeons  (Billroth) ;  on  the  con- 
trary, bad  results,  such  as  premature  softening,  rupture  of  the  tumours 
through  the  skin,  sloughing,  etc.,  were  obtained.  The  treatment  of  tu- 
mours by  parenchymatous  injections  was  first  introduced  by  Thiersch. 
In  cases  of  inoperable  tumours  erysipelas  has  been  inoculated  by  means 
of  cultures  of  the  erysipelas  coccus,  after  Busch  had  observed  that,  as 
a  result  of  erysipelatous  inflammation,  tumours,  such  as  sarcoma  of  the 
face  or  neck,  disappeared  by  fatty  degeneration.  Janicke  and  Keisser 
were  able  to  demonstrate  by  microscopic  examination,  in  a  case  of  car- 
cinoma with  fatal  erysipelas  due  to  inoculation,  that  the  cancer  cells 
are  actually  destroyed  by  the  erysipelas  cocci.  One  should,  however, 
take  into  account  that  such  an  inoculation  may  cause  death,  and  hence 
one  should  warn  the  patient  of  the  danger  of  the  treatment. 

The  man  who  succeeds  in  discovering  a  really  successful  method  of 
treating  malignant  tumours — carcinomata,  for  example — would  deserve 
to  be  honoured  by  humanity  for  all  time  as  being  its  greatest  bene- 
factor. 

§128.  The  Different  Varieties  of  TvLmoxuB.^  Connective-tissue  Tu- 


§  128.] 


THK    DIFFERENT   VARIP]TIES  OF   TUMOURS. 


747 


Fig.  400.— Hard  fibroma  of 
the  .skin  of  the  nose  (Bill- 
roth). 


viours ;  FihrouHi. —  Of  the  ditfereiit  varieties  of  coiiiiective-tissiie 
tmuours,  we  shall  first  take  up  the  fibroma,  which  is  made  up  almost 
entirely  of  this  kind  of  tissue.  We  distinguish  ordinarily  a  "hard  (P'ig. 
400)  and  a'soft  (Figs.  4Ul,  402)  form.  ''The  hard  fibroma  is  made  up,  as 
a  rule,  of  bundles  of  tough,  coarse  fibres  with 
few  cells,  while"  the  soft  form  consists  of  loose 
connective  tissue  having  a  great  number  of  cells. 
There  are,  of  course,  numerous  transition  forms. 
The  soft  fibroma  (fibroma  molle)  is  also  called 
fibroma  molluscum  by  Virchow  (Figs.  401,  402). 
The  vascularity  of  the  fibromata  varies  greatly, 
being  sometimes  very  slight,  and  again  so  marked 
as  to  give  rise  to  large  dilatations  of  the  blood 
and  lymph  vessels,  as  in  the  diffuse  hyperplasia 
of  tissue  found  in  elephantia.sis.  Fibroma  mol- 
luscum must  not  be  confounded  with  the  so- 
called  molluscum  contagiosum  (see  page  773). 

The  retrograde  changes  that  take  place  in  fibromata  are  fatty 
degeneration,  calcification,  softening,  the  formation  of  cavities  and 
cysts,  and  a  perforation  of  the  skin  with  the  formation  of  ulcers  as  a 
result  of  long-continued  traumatic  irritation  from  without,  and  of  in- 
flammation leading  to  the  formation  of 
abscesses.  The  fibroma  only  becomes 
dangerous  from  its  location  and  size,  the 
latter  being  sometimes  vei-y  great,  par- 
ticularly in  the  case  of  fibroma  of  the 
skin  or  uterus  (Fig.  402).  In  other  re- 
spects the  fibroma  is  a  perfectly  benign 
neoplasm,  giving  rise  to  no  metastases, 
although  it  is  found  multiple,  especially 
in^he  .skin,  where  it  may  appear  in  vast 
numbers.  The  multiple  fibromata  of  the 
skin  (Fig.  402)  may  be  the  size  of  a  pea 
or  walnut,  or  they  may  grow  and  form 
very  large  soft  tumors ;  they  are  some- 
times accompanied  by  disturbances  of  the 
general  nutrition  (so-called  leontiasis,  Vir- 
chow).   I  cannot  discuss  here  the  question 

(see  §  85)  whether  in  such  ca.ses  we  do  not  really  have  to  do  with  leprosy. 
According  to  the  investigations  of  Recklinghausen,  the  multiple  soft 
fibromata  of  the  skin  develop  particularly  from  the  connective-tissue 
sheaths  of  the  sebaceous  glands,  vessels,  and  nerves  (neuro-fibroma). 


Fig.  401. — Soft  fibroma  of  the  face 
(elephantiasis  faciei)  of  a  twenty- 
four-year-old  woman  (Schiiller, 
Greifswald  clinicj. 


748 


TUMOURS. 


Many  soft  fibromata  are  diifuse,  hyperplastic  formations,  and  represent 
a  transition  to  elepliantiasis,  as  seen  in  Fig.  401.  These  formations 
are  sometimes  called  cutis  pendula  or  elephantiasis  of  the  skin.     There 

are  also  observed  in  some 
cases  pigmentations  which 
take  the  form  of  congeni- 
tal moles,  or  of  brown  dis- 
colouration s  with  a  growth 
of  hairs  (see  Angeioma, 
page  755).  Many  of  the 
soft  fibromata  develop 
into  angeiomata,  caverno- 
mata,  and  lymphangeio- 
mata.  Just  as  in  the  skin, 
there  are  also  found  in 
the  internal  organs  difliuse 
fibromata,  which  in  these 
structures  likewise  de- 
velop from  the  connec- 
tive-tissue sheaths,  espe- 
cially of  the  glandular 
ducts  and  vessels;  amongst 
these  is  the  fibroma 
vegetans  intercanaliculare 
mammae. 


Fig.  402. — Multiple  soft  fibromata  of  the  skin  (fibroma 
molluscum  multiplex,  Virchow)  occurring  on  a  forty- 
seven-year-old  woman  (Virchow). 


Keloid. — In  speaking  of  the  hard  fibromata,  mention  should  be 
made  of  the  keloid,  i.  e.,  a  tumour-like,  fibrous  degeneration  of  the  skin 
and  subcutaneous  tissue  in  the  form  of  a  tough  swelling  which  sends 
out  cord-like  processes  into  the  healthy  surrounding  parts.  In  by  far 
the  majority  of  cases  the  keloid  develops  within  a  cicatrix  (cicatricial 
keloid).  We  distinguish,  as  do  Warren,  Kaposi,  Deneriaz,  and  others, 
three  forms  of  keloid  :  (1)  a  spontaneous,  (2)  a  cicatricial  keloid,  and 
(3)  the  hypertrophied  cicatrix.  Scrofulous,  tubercular  and  syphilitic 
individuals  seem,  especially  prone  to  keloid.  Deneriaz  is  disposed  to 
think  that  keloid  is  caused  by  infection  with  microbes.  It  is  char- 
acteristic of  keloid  to  recur  almost  invariably  after  extirpation. 
Leloir  and  Vidal  recommend,  in  true  keloid,  multiple  scarifica- 
tions, which  should  be  made  in  different  directions  during  several 
sittings,  and  followed  by  the  application  of  a  moist  dressing  with 
compresses  wet  in  boric-acid  solution,  and  on  the  next  day  of  a  mer- 
curial plaster. 

Fibromata  are  most  commonly  found  in  the  skin  and  subcutaneous 


§128.J  THE   DIFFERENT  VARIETIES  OF  TUMOURS.  749 

tissue,  in  the  nerves,  periosteum,  bone,  uterus,  and  ovaries.  Some  of 
the  polyps  wliieh  form  iii  the  facial  cavities — many  nasal  polyps,  for  ex- 
ample— are  periosteal  fibromata.  There  are  sometimes  seen,  especially 
n  the  pharynx,  polyps  which  are  covered  with  hairs  and  possess  an 
epidermis,  rete  Malpighii,  and  corium,  and,  according  to  Arnold,  origi- 
nate from  strayed  embryonic  cells.  They  belong,  probably,  to  the  tera- 
tomata  (see  page  787). 

Combination  or  mixed  fibrous  tumours  include  fibro-myxoma,  fibro- 
myoma,  fibro-sarcoma,  iibro-neuroma,  libro-angeioma,  fibro-cavernoma, 
libro-lvmi)hani!;eioma. 

The  diagnosis  of  lil)roma  can  be  easily  made  from  what  we  liave 
stated  in  describing  the  neo])lasm. 

Treatment  of  Fibroma. — The  treatment  of  a  fibroma  consists  in  its  re- 
moval by  the  knife,  the  galvano-cautery  or  the  thermo-cautery.  Large 
diffuse  fibromata  of  the  skin  are  to  be  extirpated  in  several  sittings 
by  cuneiform  excisions  followed  by  deep  sutures.  Billroth  once  j-e- 
moved  a  large  tumour  in  twenty  sittings.  I  removed  an  extensive  dif~ 
fuse  fibroma  involving  almost  the  entire  scalp  in  one  sitting,  and  cov- 
ered the  surface  of  the  wound  with  Thiersch  skin  grafts.  In  cases  of 
very  large  fibromata  of  the  uterus  one  must  often  give  up  all  idea  of 
extirpation,  and  treat  with  injections  of  ergotine,  or,  in  order  to  stop  the 
frequent  hsemorrhages,  remove 
both  ovaries  (Hegar).  The  de- 
scription of  operations  for  fibro- 
ma of  the  uterus,  etc.,  is  found 
in  the  Special  Surgery. 

Fibromata  of  nerves  can 
usually  be  removed  and  the 
continuity  of  the  nerve  pre- 
served (see  Neuroma).  If  the 
nerve  cannot  be  saved,  the 
nerve  stumps  can  sometimes  be 
united  after  the  extirpation  of  ^"^-  ^o^-^'^-^^  ^.^  -y^^,"-  «f  *e  cervical 
the  tumour  by  suture,  or  by  the 

use  of  the  neuroplastic  methods  described  on  pages  470-472. 
^.  Myxoma. — The  myxoma  is  made  up  of  a  soft,  gelatinous  tissue. 
The  microscopic  examination  shows  the  presence  of  a  mucoid  ground 
substance  with  a  fibrillar  framework  and  round,  spindle-shaped  or 
star-shaped  cells.  The  latter  liave  usually  many  branches  and  pro- 
cesses which  interlace  with  one  another  (Fig.  403).  Koster  has  denied 
that  the  myxoma  is  a  special  form  of  tumour,  and,  as  a  matter  of  fact,  it 
is  possible  to  look  upon  it  as  in  the  main  a  softened,  cedematous  fibroma 


750  TUMOURS. 

or  lipoma  (myxo-fibroma,  myxo-lipoma).  Myxomatous,  softened  areas 
are  often  found  in  cartilaginous  tumours. 

The  mvxomata  are  met  with  most  commonly  in  the  skin  and  sub- 
cutaneous tissue,  in  the  periosteum,  medulla  of  bone,  fasciae,  muscular 
sheaths,  nerves,  and  in  the  brain  and  its  coverings.  They  sometimes 
attain  a  very  large  size. 

The  treatment  of  a  myxoma  consists  in  its  removal  according  to 
the  above  rules. 

Lipoma. — The  lij)oma  (fatty  tumourj  is  a  lobulated  tumour  made  up 
of  fatty  tissue,  sometimes  soft  and  sometimes  firm  in  consistency.  The 
lipomata  are  either  circumscribed  or  diffuse  growths,  and  frequently 
possess  a  pedicle.  According  to  their  location,  there  may  be  distin- 
guished  cutaneous  and  subcutaneous,  subserous  (subperitoneal),  sub- 
synovial,  submucous,  inter-  and  intramuscular  (subfascial,  peritendi- 
nous) and  periosteal  lipomata.  The  lobes  of  fat  of  which  the  lipoma 
is  made  up  are  usually  held  together  by  bands  of  connective  tissue. 
Increased  development  of  the  stroma  gives  rise  to  the  lipoma  fibro- 
sum.  In  some  instances,  especially  in  the  region  of  the  neck  and  shoul- 
der, very  diffuse  lipomata  are  found.  Growth  of  the  fatty  villi  in  the 
joints,  of  which  the  knee  is  a  prominent  example,  gives  rise  to  the 
lipoma  arborescens.  Similar  diffuse  lipomata  are  found  on  the  ten- 
don sheaths.  The  articular  lipomata  probably  develop  as  a  result  of 
traumatic  ruptures  of  the  synovial  membrane,  causing  a  prolapse  of 
the  retrosynovial  fat  into  the  joint ;  they  are  also  encountered  in  ar- 
thritis deformans.  The  subperitoneal  and  submucous  lipomata  which 
develop  upon  the  stomach  and  intestine  are  of  special  clinical  impor- 
tance. The  lipomata  of  the  intestine  occasionally  give  rise  to  intesti- 
nal obstruction.  According  to  Sutton,  two  forms  of  lipoma  are  found 
attached  to  the  spinal  cord.  In  most  cases  they  are  the  result  of  the 
change  of  the  sack  of  a  spina  V)ifida  into  fatty  tissue  ;  less  frequently 
they  are  intradural  lipomata  which  grow  around  the  spinal  cord.  The 
lipomata,  as  we  remarked  before,  sometimes  change  into  fibromata, 
myxomata.  sarcomata,  and  cavernous  tumours.  They  may  attain  a 
considerable  size,  especially  when  situated  on  the  back,  and  growths  of 
this  kind,  weighing  twenty  to  twenty-five  pounds,  have  been  success- 
fully removed  (Billroth.  Hahn,  and  others ).  Pick  published  an  account 
of  a  subserous  lipoma  of  the  abdomen  weighing  twenty-nine  pounds. 
The  lipoma  is  a  benign  tumour,  and  does  not  give  rise  to  metastases, 
though  it  is  sometimes  multiple.  They  are  most  likely  to  develop  in 
individuals  from  thirty  to  fifty  years  of  age,  but  are  sometimes  con- 
genital, in  which  case  they  are  usually  diffuse,  often  combined  with 
teleangeiectases,  dermoid  cysts,  and  fibromata,  and  occur  principally  in 


§  128.] 


THE   DIFFERENT  VARIETIES  OF  TUMOURS. 


751 


the  Imnbar  region  and  on  the  buttocks.  The  so-called  "  false  tail  "  is 
merely  a  con(z;enital  lij)oma  pendulum  which  is  situated  above  the  anus, 
and  may  occasionally  be  combined  with  spina  bifida  (Bartels). 

Quite  recently  Grosch  has  published  the  results  of  very  exhaustive 
studies  on  this  sul)ject,  which  place  the  seemingly  simple  lipomata  in 
a  new  light,  lie  has  attempted  to  show  that  certain  tumours  are 
prone  to  develop  upon  particular  parts  of  the  I)ody,  mainly  on  account 
of  definite  anatomical  conditions  and  structural  peculiarities  which 
these  parts  possess.  The  lipomata  appear  to  have  a  specially  marked 
tendency  to  grow  in  certain  localities,  being  most  common  on  the 
front  and  back  of  the  neck,  on  the  posterior  aspect  of  the  trunk,  about 
the  shoulder,  and  on  the  upper  and  lower  extremities.  They  are  sel- 
doni  encountered  on  the  head,  and  then  more  often  on  the  face  than 
on_the  scalp,  being  rarest  in  the  latter  region  (Konig,  Gussenbauer). 
Grosch  states  that  they  occur  most  commonly  in  the  integument  of 
those  parts  of  the  body  which  have  a  scanty  covering  of  hair  and  a 
small  number  of  sweat  and  sebaceous  glands.  These  glands  eliminate 
fats  and  their  derivatives  in  addition  to  disintegrated  products  of  meta- 
bolism, and  hence  the  amount  of  their  secretion  is  an  important  index 
of  the  amount  of  the  subcutaneous  fat.  Obesity  and  lipoma  formation 
are,  according  to  Grosch,  quite  identical.  In  many  cases,  particularly 
in  thin  individuals,  the  lipomata  are  neuropathic  in  nature,  and  pos- 
sibly are  the  result  of  a  diminution  in  the  secretion  of  the  sebaceous 
and  sweat  glands  due  to  disturbances  in  the  central  nervous  system. 
Symmetrical  lipomata,  in  particular,  result  in  this  way. 

The  diagnosis  of  a  lipoma  is  made  chiefly  from  its  soft,  movable, 
lobulated  character.  If  pressure  is  exerted  upon  the  tumour,  as  a  rule 
there  will  be  felt  a  distinct 
crepitation  caused  by  the 
crushing  of  single  lobes 
of  fat.  The  skin  over 
the  lipoma  shows  little 
shallow  depressions  which 
are  particularly  plain  when 
the  tumour  is  encircled 
by  the  hand. 

The  extirpation  of  li- 
pomata by  the  knife  and 
scissors  is  very  easy  even  in 
the  case  of  large  tumours. 
if,  Chondroma  or  Enchondroma. — The  chondroma  consists  essentially  of 
cartilage,  most  commonly  hyaline,  less  often  fibrous  or  reticular.     The 


S';V 


^:i^& 


Fig.  404.— Small  -  celled 
chondroma  of  the  tin- 
fjer.     X  80. 


Fig.  405. — Larce-celled  chon- 
droma of  the  pelvis  very 
rich  in  cells,     x  80. 


752 


TUMOURS. 


cells  which  this  kind  of  tumour  contains  may  be  small  (Fig.  404)  or 
large  (Fig.  405),  and  their  quantity  varies  within  wide  limits.  The 
enchondromata  are  most  often  encountered  in  places  where  cartilage 
normally  exists  —  hence,  upon  the '  skeleton  (epiphyses,  periosteum, 
medulla  of  bones) — though  they  are  also  met  with  in  the  parotid  and 
thyroid  glands,  mamma,  and  testicle.  The  enchondromata  of  the  skin 
and  internal  organs  develop  partly  from  stray  cartilage  cells  and  partly 
from  transformed  connective-tissue  cells,  especially  the  endothelia  of 
the  connective-tissue  sheaths  and  of  the  blood  and  lymph  vessels. 
Thus  chondro-endotheliomata  are  sometimes  seen.  The  enchondromata 
which  grow  directly  from  cartilage — that  of  the  epiphyseal  line,  for 
example — are  also  called  ecchond roses.  Like  the  exostoses,  the  enchon- 
dromata are  often  multiple,  and  appear  in  great  numbers.  Very 
remarkable  cases  of  multiple  enchondromata  of  different  bones,  com- 
bined with  venous  angeiomata  of  the  soft  parts,  have  been  described  by 
Kast,  Recklinghausen,  and  others.  Probably  both  kinds  of  tumours 
were  the  result  of  disturbances  of  circulation.  Enchondromata  are 
comparatively  often  the  seat  of  degenerative  changes,  such  as  myxoma- 
tous softening  and  cyst  formation.  The  most  important  mixed  forms 
of  chondroma  are  the  osteochondroma  and  chondrosarcoma.  Clion- 
dromata  may  eventually  become  entirely  ossified.  I  have  also  seen  a 
chondroma  combined  with  a  melanosarcoma — 
on  the  hand,  for  example.  Not  infrequently 
enchondromata  are  found  multiple  in  different 
parts  of  the  body.  The  simple  enchondroma 
is  in  general  a  benign  neoplasm,  but  malignant 
forms  with  metastases  do  occur.  It  is  most 
often  found  in  young  subjects.  The  tumours 
attain  at  times  a  very  considerable  size,  espe- 
cially when  situated  upon  the  pelvis  or  the 
femur.  A  favourite  locality  for  enchondromata 
is  the  fingers,  where  they  form  characteristic 
nodular  tumours  (see  Fig.  406).  They  may 
also  originate  from  cartilage  cells  in  the  ethmoid 
bone,  and  grow  as  an  osteochondroma  or  car- 
tilaginous exostosis  into  the  frontal  sinus  and 
nasal  cavity.  These  osteochondromata  or  ex- 
ostoses of  the  frontal  sinuses  and  nasal  cavity 
can  become  detached,  and  are  then  found  in 
these  cavities  in  the  form  of  free  bodies  or  dead 
osteochondromata  or  osteomata.  I  once  published  a  typical  case  of 
this  kind.     The  frequency  with  which  enchondromata  or  ossified  chon- 


FiG.  406.  —  Euchoiidronia  of 
the  fiiiEfers  of  the  left 
hand  of  a  twenty-year- 
old  spinner  (Leo). 


§  128.] 


THE   DIFFERENT  VARIETIES  OF  TUMOURS. 


753 


di'omata  (exostoses)  of  the  ethmoid  Ixjiie  occur  can  he  explained  by  the 
fact  that  remnants  of  the  cartihiginuus  cranium  ixMnuin  in  this  locality 
for  a  comparatively  long  time. 

The  location  and  the  hard  nodular  consistency  of  the  tumours  are 
important  factors  in  making  the  diagnosis.  The  treatment  consists  in 
their  ])r(»m]H  removal  with  the  hammer  and  chisel. 
^,  Osteoma. — The  osteoma  is  a  tumour  made  up  of  bone,  and  occurs 
not  only  upon  the  skeleton,  but  also  in  the  skin,  muscles,  tendons, 
lungs,  ])ar()tid  gland,  and  brain.  We  have  already  spoken  of  diffuse  and 
circumscribed  osteomata — the  hyperostoses  and  osteophytes — in  con- 
nection with  inflammations  of  bone  (see  page  620),  and  of  the  so-called 
"  riding  "  or  '*  exercise  "  bones  which  develop  in  the  muscles  (see  page 
551),  and  of  the  diffuse  formation  of  bone  which  takes  place  in  myo- 
sitis ossificans  progressiva  (see  page  552).  The  development  of  bone 
in  tissues  where  bone  is  usually  not  present  is  best  explained  by  Cohn- 
heim's  theory — i.  e.,  by  supposing  that  strayed  embryonic  cartilage, 
]jeriosteal  or  medullary  cells  have  led  to  the  production  of  osseous 
tissue.  Osteomata  also  frequently  appear  upon  bones  after  fractures. 
I  once  successfully  removed  such  a  one,  almost  as  large  as  a  fist,  from 
the  horizontal  and  descending  ramus  of  the  pubic  bone,  where  it  had 
followed  a  fracture. 

The  osteomata  situated  on  the  surface  of  bones  are  also  called  exos- 
toses (Fig.  407),  and  tliose  in  the  interior  of  bones  enostoses.  The  exos- 
toses which  are  developed  in  the 
periosteum  are  sometimes  very  mov- 
able, and  do  not  have  a  direct  con- 
nection with  the  bone.  Their  struc- 
ture is  in  some  cases  as  compact  as 
ivory  (osteoma  eburneum),  and  in 
other  cases  spongy  (osteoma  spon- 
giosum). Many  osteomata  have  a 
covering  of  cartilage  (exostosis  car- 
tilaginea),  and  this  is  especially  true 
of  the  exostoses  in  the  neighbour- 
hood of  the  epiphyseal  cartilage, 
which  are  really  ossified  enchondromata  or  ecchondroses  (ecchondrosis 
ossificans).  The  cartilaginous  exostoses  (osteomata  with  a  covering  of 
hyaline  cartilage)  are  sometimes  styloid  or  finger-shaped,  and  resemble 
a  metacarpal  or  metatarsal  bone.  These  cartilaginous  exostoses,  or 
rather  ossified  chondromata,  are  often  multiple,  occurring  in  the  neigh- 
bourhood of  the  epiphyses  of  many  different  bones  in  the  same  individ- 
ual. Occasionally  the  influence  of  heredity  is  very  noticeable.  Hey- 
48 


Fig.  407. — Exostosis  of  the  femur  (Buscli). 


754  TUMOURS. 

raann  observed  multiple  cartilaginous  exostoses  on  many  of  the  bones  of 
a  phthisical  patient  whose  mother  and  four  brothers,  as  well  as  his  three 
children,  all  had  a  similar  peculiarity.  Reinecke  collected  thirty-six 
cases  of  multiple  exostoses  from  literature,  in  which  the  hereditary 
predisposition  could  be  traced  back  in  one  case  five  generations,  in 
fifteen  cases  three  generations,  and  in  twelve  cases  two  generations.  In 
such  instances  the  development  of  the  exostoses  is  due  to  an  inherited 
predisposition,  and  begins  usually  in  the  third  or  fourth  year  of  life. 

By  exostosis  hwsata  is  meant  an  exostosis  which  is  covered  by 
a  bursa.  It  develops  principally  in  the  joints,  from  the  articular  car- 
tilage, and  pushes  the  synovial  membrane  before  it.  The  pocket  thus 
made  in  the  capsule  of  the  joint  either  remains  open,  so  that  the  bursa 
retains  its  connection  with  the  joint,  or  it  becomes  entirely  cut  off 
from  the  latter  (see  page  690). 

These  bursal  or  synovial  exostoses  generally  contain  a  fluid  resem- 
bling synovia,  and  several  free-joint  bodies  usually  made  up  of  hyaline 
cartilage.  This  form  of  exostosis  may  also  occur  at  some  distance 
from  a  joint,  and  even  upon  the  bones  of  the  trunk  and  ribs ;  in  these 
cases  the  enveloping  sack  forms,  after  the  fashion  of  an  accessory, 
mucous  bursa.  The  exostoses  can  become  gradually  or  suddenly 
detached  by  traumatisms,  for  example,  and  *then  persist  as  dead  pieces 
of  bone,  like  the  free  dead  osteomata  in  the  frontal  sinuses  and  nasal 
cavity. 

Osteomata  of  the  teeth  and  alveolar  processes  are  comparatively 
common.  The  tumours  of  the  teeth,  the  so-called  odontomata,  which 
consist  of  dentine  and  enamel,  arise  from  the  pulp  or  degenerated 
embryonic  tooth  cells  as  a  result  of  anomalies  during  the  period  of 
development  of  the  teeth,  and  sometimes  in  young  subjects  after  inju- 
ries. The  true  odontomata  are  rare,  and  are  found,  according  to 
Heath,  almost  exclusively  on  the  lower  jaw.  Lloyd  saw  an  odontoma 
of  the  upper  jaw,  and  ]\[etnitz  has  published  an  account  of  five  cases  of 
this  rare  form  of  tumour,  and  thinks  that  want  of  room,  abnormal  posi- 
tion of  the  neighbouring  teeth,  and  inflammatory  processes,  especially 
chronic  periostitis,  are  important  factors  in  their  etiology.  In  general, 
two  formsof  odontoma  can  be  distinguished — soft  and  hard — or,  l)etter, 
those  with  dentine  and  those  without  (Partsch).  The  exostoses  which 
form  on  teeth  are,  of  course,  not  to  be  counted  amongst  the  odontomata, 
but  amongst  the  osteomata. 

The  osteomata  are,  on  the  whole,  benign  tumours,  and  usually  grow 
slowly,  but  sometimes  are  found  multiple,  occurring,  for  example,  on 
numerous  epiphyses,  where  they  are  capable  of  causing  disturbances  of 
growth.     In  cases  of  multiple  exostoses  of  the  bones  of  the  cranium 


§  128.J 


TIIR   DIFPERJ^NT   VARIETIES  OF  TUMOURS. 


755 


Fig.  408. — Osteosareonia  (osteoid,  ma- 
lignant exostosis)  of  the  superior 
maxilla  (Busch). 


and  ftice,  atrophy  of  the  lattur  has  been  observed  as  a  result  of  inter- 
ference witli  its  development.  The  malignant  osteoinata  include  the 
osteosarcoma,  also  called  osteoids  (see 
Fig.  408),  which  give  rise  to  extensive 
local  destruction  of  tissue  and  to  metas- 
tases (see  sarcoma).  In  this  category 
belongs  also  the  very  vascular  (pulsa- 
ting) osteosarcoma.  For  cysts  of  bone 
see  page  785. 

Pointed  exostoses  can  sometimes 
cause  injuries  to  large  arteries  and  veins, 
and  thus  lead  to  the  formation  of  aneu- 
rysms, as  in  the  instances  observed  by 
Boling,  K lister,  and  others.  In  Kiis- 
ter's  case  a  pointed  osteophyte  wounded  the  popliteal  artery  and  led  to 
the  formation  of  an  aneurysm.  After  removal  of  the  osteophyte  by 
a  chisel,  and  double  ligation  of  the  popliteal  artery,  a  rapid  recovery 
was  made.  Kronlein  observed,  on  the  other  hand,  that  a  traumatic 
aneurysm  of  the  popliteal  artery  which  had  lasted  ten  years  caused 
an  erosion  and  formation  of  osteophytes  on  the  lower  end  of  the 
femur. 

The  diagnosis  of  osteomata  can  usually  be  made  from  their  location 
and  hard,  bony  consistency. 

Osteomata  are  usually  removed  by  the  chisel  or  saw,  or  when  in  the 
soft  parts,  by  extirpation  with  the  knife. 
In  cases  of  exostoses  in  the  vicinity  of  a 
joint  one  should  always  think  of  the  pos- 
sibility of  their  communicating  with  the 
joint.  In  such  cases  the  tumour  is  only 
removed  wlien  it  causes  serious  trouble.  / 
_>,  Angeioma  {Blood  -  vessel  Tumour).  — 
The  angeiorna  is  made  up  principally  of 
newly  formed  and  old,  dilated,  hypertro- 
phied  blood-vessels.  Three  varieties  are 
distinguished  : 

1.  The  angeiorna  simplex  (teleangeiec- 
tasis,  nsevus  vasculosus,  plexiform  angei- 
oma),  consists  of  dilated,  tortuous,  and 
newly  formed  capillaries  and  small  ves- 
sels. Macroscopically,  the  teleangeiectases  are  mostly  soft  swellings, 
bright-  to  dark-red  in  colour,  which  are  only  slightly  elevated  above 
the  surface  of  the  skin,  where  they  are  usually  found.     They  are  very 


Fig.  409. — Congenital  telangiecta- 
sis (birtli  -  mark)  with  hairs 
(Masion). 


756 


TUMOURS. 


often  congenital,  forming  the  so-called' birth-mark.  These  birth-marks 
are  often  associated  with  hypertrophy  and  pigmentation  of  the  skin, 
and  very  frequently  with  hair-formation  (see  Figs.  409  and  411).  Many 
of  these  hairy  birth-marks  are  diffuse,  soft  fibromata,  others  more  like 

teleanffeiectases.  The  hair-formation  often 
resembles  the  hide  of  animals,  such  as  rats, 
monkeys,  or  rabbits.  The  mothers  of  such 
children  often  say — as  in  the  cases  illus- 
trated in  Figs.  409,  410 — that  they  were 
frightened  during  pregnancy  by  the  sud- 
den appearance  of  the  animal  whose  skin 
resembles  that  of  the  birth-mark.  The 
marked  heteroplastic  development  of  hair 
on  certain  parts  of  the  body  which  are  cov- 
ered with  an  otherwise  normal  skin — the 
growth  of  a  beard  in  women,  for  exam- 
ple ^hypertrichosis  circumscripta) — and  the 
growth  of  hair  over  the  entire  body  (hy- 
pertrichosis universalis),  have  nothing  to 
do  with  tumour-formation ;  it  is  mostly  a 
hereditary  malformation  which  is  found  in 
certain  families.  Several  families  of  hairy 
people  are  known  in  which  the  complete  covering  of  the  body  with 
hair  was  inherited  by  the  children.  Fig.  411  represents  Schwe-Maong, 
the  father  of  an  Asiatic  hairy  family,  and  Fig.  412  the  Russian  hairy 

man  Andrian,  whose 
son  had  the  same  pe- 
culiarity. Treatment 
by  the  galvano-cau- 
tery  may  be  used  for 

this  abnormity. 

Kr:■^!i',ll\l"■lMraifflHi  m  Mm^,,jln!lllKmW  'The    angeiomata 

also  include  the  an- 
eurvsma  anastomoti- 


FiG.  410. — Very  large  congenital 
hairy  birth-mark  on  the  back, 
neck,  and  upper  extremity  of 
a  twelve-year-old  girl  (Beigel 
and  Paget). 


Fig.  411.  — Shwe-Maonjr, 
ancestor  of  an  Asiatic 
hairy-family. 


Fig.  412. — Andrian,  a  Russian  hairy 
man  (Virchow  and  Bartels). 


cum  or  racemosum, 
which  is  best  called 
angeioma  arteriale 
racemosum  or  cir- 
soid aneurysm,  and 
has  been  described  in  a  previous  chapter  (Fig.  413).  The  cirsoid  aneu- 
rysm, as  we  saw  on  page  535,  is  the  result  of  a  pampiniform  dilatation, 
tortuosity,  and  thickening  of  the  arteries  supplying  a  certain  region, 


§  128.] 


TlIK    DIFFERENT   VARIETIES  OP  TUMOURS. 


757 


and  is  due  partly  to  the  formation  of  new  vessels  and  partly  to  liyper- 
tr(»i)hy  of  the  old  ones. 

^.  The  cavernous  migeioma  (tumor  cavernosus)  resembles  in  struc- 
ture the  corpus  cavernosum 
• — i.  e.,  it  consists  of  cavities 
lined  with  endothelium,  which 
are  filled  with  lluid  or  coagu- 
lated blood,  and  separated  by 
connective-tissue  septa.  It  is 
most  commonly  found  in  old 
people  in  the  liver,  skin,  sub- 
cutaneous tissue ;  less  often 
in  the  brain,  spleen,  kidneys, 
u_terus,  or  bone.  The  views 
as  to  its  origin  do  not  agree. 
According  to  Eokitanski,  the 
cavernous  spaces  are  first 
formed  from  the  connective 
tissue,  and  then  secondarily 
become  joined  with  the  blood- 
vessels and  thus  filled  with 
blood.  Another  explanation 
seems  to  me  the  more  prob- 
able— viz.,  that  a  dilatation  of 
the  capillaries  first  takes  place, 
and  subsequently  the  walls  of 
the   dilated   capillaries  which 

he  next  one  another  gradually  disappear,  resulting  in  the  formation  of 
large  cavities  filled  with  blood. 

Angeioma  is  not  infrequently  combined  with  fibroma,  lipoma,  and 
sarcoma  (angeiosarcorna). 

The  treatment  of  angeiomata  consists  in  their  extirpation  with  the 
knife,  if  possible,  or  with  the  galvano-cautery  or  thermo-cautery  (so- 
called  ignipuncture  or  punctiform  ustion).  In  order  to  operate  with- 
out loss  of  blood,  the  base  of  the  angeioma  may  in  appropriate  cases  be 
transfixed  and  tied  off  in  two  or  more  parts,  or  portions  of  the  tumour 
may  be  seized  by  clamps  before  they  are  divided.  Large,  diffuse 
angeiomata,  like  cirsoid  aneurysms,  ma}^,  if  removal  is  impossible,  be 
treated  by  ligation  of  the  afferent  arteries  combined  with  ignipuncture. 
Cirsoid  aneurysm  occurs  most  commonly  on  the  scalp,  and  in  this 
situation  might  require  ligation  of  the  external  carotid.  If  the  main 
artery  is  too  short,  each  of  its  branches  should  be  secured.     It  is  dan- 


Fig.  41.3. — Angeioma  arteriale  raceraosuni  (cirsoid 
aneurysm)  of  the  art.  angularis  and  frontalis 
dextra  et  sinistra  of  a  twenty-year-old  man 
(Bruns'l.  Ligation  of  the  right  external  carotid 
and  left  common  carotid.  Death  due  to  cere- 
bral embolism. 


758 


TUMOURS. 


gerous  to  ligate  the  common  carotid  on  account  of  the  changes  which 
may  thus  be  produced  in  the  cerebral  circulation.  For  the  purpose  of 
preventing  recurrences  it  is  often  advisable  to  apply  to  the  diseased 
part  for  a  considerable  time  dressings  which  exert  pressure  or  to  paint 
it  with  iodoform  collodion.  Amongst  other  methods  which  have  been 
recommended  are  electrolysis,  parenchymatous  injections  of  the  tinc- 
ture of  iron,  liquor  ferri  (Monsell's  solution),  absolute  alcohol,  liquor 
Piazza  (sodii  chlor.  15'0  grammes ;  liq.  ferri  sesquichlorati  [thirty  per 
cent.],  20'0  cubic  centimetres ;  aq.  destil,  60'0  cubic  centimetres  [St. 
Germain]).  Great  care  should  be  taken  not  to  make  the  injection  into 
healthy  subcutaneous  tissue.  Gunn  and  Haven  speak  well  of  the  injec- 
tion of  carbolic  acid  (ninety-live  per  cent.  acid,  carbol.  and  glycerine,  aa) 
into  the  peripheral  parts  of  the  angeioma  (a  few  drops  in  from  five  to 
fourteen  different  places).  Setons  made  of  threads  saturated  in  liquor 
fer2'i,  and  then  dried  and  passed  through  the  growth,  used  to  be  em- 
ployed, as  were  also  the  ligature  (see  page  72),  cauterisation  with  fum- 
ing nitric  acid,  etc.  These  are  all  methods  of  treatment  which  have 
now  become  obsolete. 

Vr  LyvapliSingeiomdi  {Angeioma  Lymjjphaticum^  Lymphangeiectasis). — 
The  lymphangeioma  corresponds  to  the  angeioma  of  the  blood-ves- 
sels, and  consists  essentially 
of  dilated  and  hypertrophied 
lymph  vessels  (Fig.  414).  The 
following  varieties  may  be 
distinguished:  1,  lymphangei- 
oma simplex  (teleangeiecta,- 
sia  lymphatica);  2,  cavernous 
(lymphangeioma  cavernosum 
[Fig.  414])  ;  and  3,  cystic 
lymphangeioma  (lymphangei- 
oma cysticum).  Some  lym- 
phangeiectases  are  acquired 
and  others  are  congenital. 
The  great  majority  of  lym- 
phangeiomata  are  probably 
due  to  disturbances  of  em- 
bryonic development ;  a  simple  lymph  stasis  would  not  be  sufficient  to 
explain  them,  although  it  can  favour  the  growth  of  a  lymphangeioma 
which  already  exists.  They  usually  communicate  directly  with  the 
lymph  vessels,  and  in  one  case  Nasse  was  able  to  demonstrate  an  open 
connection  between  a  cavernous  lymphangeioma  of  the  neck  and  the 
subclavian  vein  and  thoracic  duet— a  circumstance  which  can  only  be 


Fig.  414.— Lymphangeioma  cavernosum  of  the  sub- 
cutaneous cellular  tissue  of  the  neck,  consisting 
of  enlarged  lymph  vessels  with  hypertrophic 
walls.     X  30. 


§  128.] 


THE   DIFFP]RENT   VARIF/riES   OF  TUMOURS. 


759 


Fig.  415. — Leiomyoma  of  the  uterus; 
some  of  the  nuclei  of  the  muscle 
fibres  have  been  cut  longitudinally, 
and  others  transversely,     x  200. 


Lymphangeiectases  are  very 


explained  on  tlie  grounds  of  a  disturbance  of  embryonic  development, 
as  mentioned  above. 

In  consequence  of  this  communication  of  a  lynipliangeioma  with 
veins  caused  l)y  abnormities  in  foetal 
development,    large    blood  -  cysts    are 
formed,  especially  on  the  neck  (Bayer). 
The  congenital  lymphangeiectatic  hy- 
pertrophy of  the  tongue  (macroglos- 
sia)  and  of  the  lips  (macroclieilia)  be- 
long to    the   congenital   lymphangeio- 
mata.      Lymphangeiomata    sometimes 
reach  a  very  considerable  size.     The 
fluid  which  they  contain  is,  as  a  rule, 
clear,   but   sometimes   milky.     If  one 
bursts,  a  lympliorrlio^a  or  lymph  fistula 
results,  through  which  large  amounts 
of  this  fluid  may  escape  (see  page  543) 
often  found  in  connection  wnth  the  diffuse  hyperplasia  of  connective 
tissue   forming    the    so-called   ele- 
phantiasis (elephantiasis  lymphan- 
geiectatica,  see  page  523). 

The  treatment  of  lymphangei- 
oma  has  already  been  spoken  of. 
When  possible,  it  consists  in  extir- 
pation of  the  growth — a  procedure 
which  is  sometimes  very  diflicult. 
Simple  incision  and  drainage,  or 
packing  with  iodoform  gauze,  may 
prove  effective  in  cystic  tumours ; 
but  this  method  shonld  not  be  used 
when  numerous  small  cavities  are 
present.  Bergmann  has  obtained 
very  good  results  from  extirpation, 
and  Rehn  successfully  removed  a 
lymphangeioma  cavernosum  of  the 
sacral  canal  which  pressed  upon 
the  Cauda  equina. 
'JJ  ■  Myoma  {Muscle  Tumour).  — 
The  myoma  is  made  up  essential- 
1}^  of  muscle  fibres,  which  may  be 
either  striated  (rhabdomyoma,  my- 
oma strio-cellulare)  or'^non-striated 


Fig.  416. — Plexiform  neuroma  of  the  lumbar 
plexus  (Czerny). 


760 


TUMOURS. 


(leiomyoma,  myoma  Igevicellulare,  Fig.  415).  Simple  rhabdoinyomata 
are  very  rare,  the  myosarcoma  being  the  most  common  tumour  of  stri- 
ated muscle.  Striated  muscle  fibres  and  spindle  cells  with  striations 
are  often  seen  in  sarcomata  of  the  testicle,  kidney,  and  in  tumours  of 
the  ovary  (myosarcoma).  Probably  in  such  cases  strayed  embryonic 
muscle  cells  have  become  deposited  in  these  organs.  '  The  leiomyoma 
is   most  common    in   the  uterus  and  intestinal  tract,  where  it  takes 

the  form  of  nodu- 
lar tumours,  which 
are  more  or  less 
pure  myomata  or 
fibro-^mj'omata.  Mi- 
croscopically, the 
non-striated  muscle 
fibres  are  recognised 
on  longitudinal  sec- 
tion by  the  rod-like 
nuclei  and  their  reg- 
ular arrangement. 
On  cross  section  the 
characteristic  con- 
tours of  the  fibres 
are  seen,  together 
with  the  transverse 
section  of  the  nu- 
clei, in  their  interi- 
or (Fig.  415).  The 
leiomyomata  of  the 
uterus  often  take  on 
secondary  changes, 
such  as  extensive  fat- 
ty degeneration,  calcification,  cyst  formation,  and  suppuration.  They 
are  occasionally  combined  with  sarcoma  and  carcinoma. 

The  treatment  of  myomata  of  the  uterus,  for  example,  is  in  the 
main  the  same  as  that  of  fibroma  (see  page  749). 
JJ.  ,  Neuroma  {Nerve-fibre  Tumour). — The  neuroma  is  made  up  essen- 
tially of  newly  formed  nerve  fibres.  A  distinction  is  made  between 
^  tjrue  and  false  neuroma.  ^  Most  neuromata  are  false — that  is,  they  are 
fibromata  or  myxomata  of  the  connective-tissue  portion  of  nerves,  with 
displacement  and  atrophy  of  the  nerve  fibres.  They  generally  form 
flask-like  swellings  of  the  nerves,  or  cylindrical  or  spherical  tumours, 
about  the  size  of  a  bean,  cherry,  or  plum,  and,  in  rare  cases,  the  size  of 


Fig.  417. — Ple.xiform  neuroma  of  the  lower  part  of  the  face  aud 
neck  on  the  right  .side  in  a  boy  ten  years  old  (Bruns). 


kA' 


§  128.] 


THE    DIFFERKNT   VARIETIES   OF   TUMOURS. 


■c>i 


I, 


JLheii's  eg<^.  The  false  ncuroiiiata  are  often  multiple.  J>ergiiiami,  for 
instance,  observed  more  than  a  Inindred  neuro-iibromata  of  the  skin 
in  a  man  tifty-four  years  old.  The  so-called  aniputation-neuromata, 
which  are  club-shaped  swellings  of  the  ends  of  the  nerves  in  amputa- 
tion-stumps, are,  as  a  rule,  made  up 

mostly  of  newly  formed  connective  tis-  ^r        "\ 

sue,  with  more  or  less  numerous  col-  /  % 

lections  of  newly  formed  nerve  fibres.  I  ^=^ 

"  The  so-called  '  plexif  orm  neuroma  also 
belongs  to  the  false  neuromata  or  fibro- 
neuromata.  It  is  essentially  a  nodu- 
lar, fibrous  degeneration  of  the  branch- 
es of  a  particular  nerve,  the  trunk  of 
which  becomes  twisted  and  tortuous 
(Figs.  41G,  419).  These  plexiform  neu- 
romata, of  which  the  rudiments  were 
present  in  the  embryo,  are  very  much 
like  soft  fibromata  of  the  skin  and  sub- 
cutaneous cellular  tissue,  in  which  they 
form  flabby,  lobulated  folds  and  ele- 
vations (Fig.  41 7),  sometimes  uneven 
and  nodulated,  usually  containing  dark 
pigment  and  covered  with  hair,  as  in 
elephantiasis  (Fig.  401).  Very  large  tumours  sometimes  result  from 
this  elephantiasis-like  hyperplasia  of  the  skin  and  subcutaneous  tissue. 
The  plexiform  neuroma  is,  according  to  Bruns,  almost  always  situated 
in  the  subcutaneous  tissue,  and  only  exceptionally  in  the  deeper  parts, 
as  in  a  case  seen  by  Pomorski,  in  which  a  plexiform  neuroma  of  the 
intercostal  nerves  had  grown  into  the  pleura.  Bruns  collected  from 
literature  a  large  number  of  instances  of  plexiform  neuroma,  and  found 
that  its  most  common  location  is  on  the  temples  and  upper  eyelid 
(fifteen  cases).  It  was  found  eight  times  in  that  part  of  the  neck  which 
lies  posterior  to  the  ears,  three  times  on  the  nose  and  cheek,  four  times 

"near  the  lower  jaw  and  front  of  the  neck,  seven  times  on  the  breast 
and  back,  and  three  times  on  the  extremities. 

■^  The  true  neuromata  consist  for  the  most  part  of  ne\vly  formed 
nerve  fibres,  which  de\^elop  in  one  or  more  peripheral  nerves.  Some 
cases  of  amputation  neuromata  also  belong  to  this  class  of  tumours. 
Depending  upon  whether  the  neuroma  is  made  up  of  medullated  or 
non-medullated  nerve  fibres,  we  make  a  distinction,  as  Yirchow  does, 
between  a  neuroma  myelinicum  and  a  neuroma  amyelinicum.  The 
brain  and  certain  neoplasms  of  the  testicle  and  ovary  are  sometimes  the 


Fig.  418. — Neuroma  amyelinicum  mul- 
tiplex recurrens  ulcerosum  anti- 
brachii.  Most  of  tlie  nodules  lie 
beneath  the  skin  :  a,  ulceratinij  nod- 
ule; h,  scar  from  a  previous  e.xtirpa- 
tion  of  the  primary  neuroma  (Vir- 
cliow). 


762 


TUMOURS. 


seat  of  a  cellular  (ganglionic)  neuroma.  The  neuroma  is  in  general  a 
benio-n  tumour,  though  it  is  sometimes  multiple  in  the  nerves  of  the 
brain  and  spinal  cord. 

In  rare  cases  neuromata  are  found  to  be  malignant,  giving  rise  to 
local  recurrences  after  extirpation,  and  even  to  metastases  (Fig.  418). 
Benign  neuromata  can  sometimes  rapidly  become  malignant  by  chang- 
ino-  into  sarcoma.  Krause  has  collected  from  literature  twenty-four 
such  cases.  Microscopically,  the  malignant  neuromata  are  usually 
niyxomata  or  lipomatous  myxomata,  or  medullary,  round,  or  spindle- 


FiG.  419. — Plexiforni  neuroma;  specimen  taken  from  the  ease  illustrated  in  Fig.  417  (Bruns). 

celled  sarcomata,  or  coarse  fibrous  neuromata,  which  nevertheless  run 
a^very  malignant  course.  Softening  and  cyst  formation  in  the  centre 
of  the  tumour  are  common.  The  malignant  neuromata  usually  spring, 
according  to  Krause,  from  the  nerve  sheaths,  especially  the  intra-fascic- 
ular  tissue.  They  can  develop  rapidly  to  tumours  the  size  of  a  man's 
head,  and  are  especially  common  on  the  large  nerves  of  the  extremities, 
such  as  the  median  and  great  sciatic,  but  are  not  infrequently  met  with 
in  the  small  cutaneous  nerves.  Newly  formed  medullated  nerve  fibres 
are  occasionally  found  in  the  neuromata — a  fact  which  is  not  reuiark- 
able,  as  we  know  that  degeneration  and  regeneration  of  nerve  fibres 
take  place  in  normal  nerves. 

The  so-called  tubercula  dolorosa,  which  appear  as  small,  moval)le, 
painful,  subcutaneous  tumours,  are,  according  to  Yirchow,  in  some  in- 
stances true  neuromata,  while  in  others  it  has  not  been  possible  to 
demonstrate  nerve  fibres. 


§128.]  TlIK    DIFFKUKNT    VARIKTIKS   OF   TUMOURS.  763 

As  rei;-ar(ls  the  treatincnt  of  neuroma,  I  may  say  that  neiiro-libro- 
inata  and  neuro-myxoniata  can  usually  be  removed  and  the  continuity 
of  the  nerve  be  })re.served.  If  e.xtiri)ation  is  not  ])ossible,  as' in  the  case 
of  large  nerves  of  the  extremities,  for  exainj)lo,  and  the  removal  of  the 
tumour  is  indicated  on  account  of  great  pain,  rapid  growth,  etc.,  the 
continuity  of  the  nerve  must  be  restored,  after  the  extirpation  of  the 
ueuroma,  by  means  of  sutures  or  a  plastic  operation.  The  treatment 
of  a  plexiform  neuroma,  which  involves  the  whole  region  of  distribu- 
tion of  a  nerve,  is  merely  palliative  in  case  an  extirpation  is  impossible. 
The  treatment  of  amputation  neuromata  was  described  on  page  12G. 
'^f  .S .  Glioma. — Gliomata  occur  especially  in  the  brain,  less  often  in  the 
spinal  cord,  and  result  from  the  growth  of  the  neuroglia  cells  of  the 
central  nervous  system.  They  form  pale-grey,  greyish-white,  or,  M'hen 
very  vascular,  recldish  or  dark-red  tumours,  which  are  usually  not  sharply 
defined.  They  are  not  infrequently  the  seat  of  retrograde  metamor- 
phoses, such  as  fatty  degeneration,  caseation,  and  softening.  Under  the 
microscope  the  gliomata  are  seen  to  be  made  up  of  a  network  of  fine, 
translucent  fibres,  which  contain  branching  cells  resembling  those  of  the 
neuroglia.  According  to  Klebs,  Heller,  and  others,  many  glioinata  con- 
sist of  growing  ganglionic  cells  and  newly  formed  nerve  fibres.  Ziegler 
is  right  in  separating  these  from  the  gliomata,  and  calls  them'  neurogli- 
qnia  ganglionare. 

II,  /  Lymphoma. — By  lymphoma  we  understand 'a  true  neoplasm  as  well 
as^  chronic  inflammatory  or  infectious  hypertrophy  of  lymph  glands. 

"■^The  latter  may  originate  as  a  result  of  local  and  constitutional  causes. 
In  this  category  belong,  for  example,  the  lymphomata  of  the  neck  fol- 
lowino;  chronic  inflammation  of  the  skin  or  mucous  membrane  in  the 
i-egion  supplied  by  the  lymphatic  vesselsjwhich  lead  to  the  enlarged 
glands,  also  the  lymphomata  due  to  local  or  general  tuberculosis,  or 
which  occur  in  the  course  of  leucsemia,  and  the  progressive  lymphoma- 
tous  formations  encountered  in  anomalies  of  the  organs  producing  the 
blood  (malignant  lymphoma,  Ilodgkin's  disease,  pseudo-leucaemia).  The 
word  lynnphoma  signifles,  in  general,  hyperplasia  of  lymph  glands,  but 
i£j;he  enlargement  is  caused  by  a  true  neoplasm,  M-e  call  it,  according 
to  its  structure,  a  lympho-sarcoma,  lympho-adenoma,  etc.  The  above- 
mentioned  progressive  formation  of  lymphomata,  the  so-called  malig- 
nant lymphoma,' is  exceedingly  interesting.  The  disease  usually  begins 
with  a  large,  nodular  swelling  of  the  lymph  glands  of  the  neck  (see 
Fig.  420)  which  is  entirely  free  from  pain.  As  a  rule,  the  nearest 
lymph  glands  become  successively  swollen,  then  the  glands  of  the  other 
side,  and,  finally,  in  many  cases  the  mediastinal  and  the  retroperitoneal 
glands.     The  microscope  shows  a  simple  hyperplasia  of  the  lympli 


7G4 


TUMOURS. 


glands,  though  Goldraann  observed  in  them  ajnarked  increase  in  the 
numl)er  of  cells  which  can  be  readily  stained  by  eosin  (eosinophilons 
cells).  Metastases  in  the  internal  organs  are  of  frequent  occurrence 
(lungs,  spleen,  liver,  kidneys,  bone),  and  the  enlargement  of  the  spleen 
may  become  very  marked.  The  general  health  can  remain  undisturbed 
for  a  comparatively  long  time,  but  ordinarily  a  steadily  increasing  loss 
of  flesh  and  strength  soon  sets  in  and  is  followed  by  death.  Occasion- 
all  v,  as  in  goitre,  the  end  comes  suddenly  from  suffocation  in  conse- 
quence of  softening  of  the  laryngeal  cartilages  or  of  paralysis  of  the 
vocal  cords  due  to  bilateral  pressure  on  the  recurrent  nerve.  The  ed- 
ology  of  malignant  lymphoma  has  not  been  thoroughly  investigated. 
The  white  blood-corpuscles  are  not  increased  in  numbers  as  in  leuca^mic 
lymphoma,  hence  the  name  pseudo-leucaemia.     Malignant  lymphoma 

or  pseudo-leucaemia  is  probably  the 
result  of  some  as  yet  unknown  in- 
fection. 

The  treatment  of  lymphoma  va- 
ries according  to  its  cause.  Neo- 
plasms of  the  lymph  glands  should 
be  extirpated  as  soon  as  possible. 
Tubercular  lymphomata  should  also 
be  treated  in  the  same  way,  or 
scraped  out  with  the  sharp  spoon, 
or  treated  by  igni puncture  with  the 
galvano-cauterv,  or  parenchymatous 
injections  of  ten-per-cent.  iodoform 
oil  or  iodoform  glycerine,  etc.  I 
also  excise  simple,  non-tubercular, 
so-called  scrofulous  hypertrophies  in  case  they  do  not  disappear  under 
a  general  tonic  regimen,  a  thing  which  is  of  great  importance  in  the  man- 
agement of  all  lymphomata.  The  arsenic  treatment  is  sometimes  suc- 
cessful, both  internally  and  in  the  form  of  parenchymatous  injections. 
Billroth  begins  with  ten  drops  of  Fowler's  solution  pro  die  internally, 
and  injects  at  first  two,  subsequently  four  to  six  drops  a  day  into  the 
substance  of  the  tumour.  The  internal  dosage  may  be  raised  two  drops 
every  third  day,  but  if  symptoms  of  poisoning  make  their  appearance 
the  doses  must  be  diminished.  A  cure  is  not  obtained  in  this  wav,  but 
the  patient  improves  and  the  course  of  the  disease  is  checked  or  ren- 
dered less  severe.  The  operative  removal  of  malignant  lymphomata  is 
probably  always  unsuccessful,  as  recurrences  appear,  as  a  rule,  very 
promptly.  But  the}'  should  be  removed  sufficiently  to  relieve  at  least 
the  urgent  symptoms,  such  as  those  caused  by  obstruction  to  respiration. 


Fig.  420. — Soft  malignant  lymphoma  of  the 
cervical  gland.s  of  a  boy  eight  years  old 
(Winiwarter). 


12H.] 


TIIH    DIFFERENT   VARIETIES  OP  TUMOURS. 


Y65 


"^'^  Sarcoma. — The  sarcoma  (Figs.  421,  422)  is  a  neoplasm  wlileh  springs 
from  connective  tissue,  and  is  formed,  in  general,  after  tlie  type  of 
embryonic  connective  tissue  with  abnormal  and  luxuriant  cell  forma- 


FiG.  421. — Sarcoma  (osteo-sarcoma) 
of  the  left  (upper)  arm  (Es- 
luarch). 


Fig.  422. — SarcomaVmyxc-sar- 
coma)  of  the  dura  mater 
in  a  twenty-eight-year-old 
man  (Ileineke). 


tion.  The  sarcomata  originate  in  all  varieties  of  connective  tissue  (car- 
tilage, bone,  periosteum,  ordinary  connective  tissue,  fat  tissue,  etc.),  and 
are  particularly  likely  to  start  from  the  cells  of  the  walls  of  tlie  blood- 
vessels.    Benign  tumours,  as  we  remarked   before,   not  infrequently 


Fig.  423.—  ■;     _  i  ortion  of  an  inter- 

muscular sarcjiiia  of  the  arm  :  <S',  sar- 
coma tis.sue  consistinsr  of  round  cells ; 
M,  transversely  divided  muscular 
tissue. 


Fig.  424. — Portion  of  a  sarcoma 
of  the  fascia  of  the  thigh 
containing  cells  of  various 
shapes  (small  and  large 
round  cells,  spindle  cells, 
polynucleated  giant  cells, 
etc.).     X  250. 


become  sarcomatous,  thus  giving  rise  to  mixed  tumours,  such  as  fibro- 
sarcoma, myxo-sarcoma,  osteo-sarcoma,  etc.  Sarcomata  in  the  skin,  peri- 
osteum and  marrow  of  bone  occasionally  appear  in  a  multiple  form. 


766 


TUMOURS. 


The  size  and  shape  of  the  cells  in  a  sarcoma  vary  within  wide  limits 
(Fio-s.  423-428),  manv  being  round  cells,  which  are  often  contractile, 
like  white  blood-corpuscles,  while  others  are  spindle  cells,'endothelial 
cells,  stellate  cells,  or'^giant  cells.  Between  each  of  these  there  are  nu- 
merous'^" intermediate  cell  forms,  and  different  shaped  cells  are  often 


-^S 
> 


\ -, 


s/ 


""^^^ 


Fig.  426.— Giaiit-celled  sarcoma  of  the 
breast,      x  300. 


Fig.  425. — Small-celled  alveolar  sar- 
coma of  the  lyinph  glands  of  the 
neck.  The  alveoli  between  the 
connective  tissue  bands  are  filled 
with  sarcomatous  round  cells. 
X  150. 

found  lying  next  one  another.  There  is  a  greater  or  less  amount  of 
intercellular  substance  which  may  be  fibrous,  homogeneous,  reticu- 
lated, granular,  mucoid,  etc.  The  vascularity  of  sarcomata  also  varies 
very  much,  being  occasionally  so  marked  that  the  tumours  pulsate  like 
aneurysms.  They  likewise  show  great  differences  in  consistency  and 
colour.  The  very  malignant,  soft,  rapidly  growing  sarcomata,  made  up 
largely  of  cells,  are  especially  to  be  dreaded  (medullary  sarcoma).  The 
pigmented  varieties,  the  melano-sarcomata,  are  also  very  malignant. 
The  formation  of  metastases  takes  place,  as  Billroth  showed,  principally 
through  the  veins,  and  to  a  less  extent  through  the  lymphatics.  I  once 
found  in  a  case  of  medullary  sarcoma  of  the  lower  extremity  a  meta- 
static deposit  the  size  of  a  small  pea  in  a  valve  of  the  femoral  vein.  The 
retrograde  metamorphoses  which  take  place  are  fatty  degeneration,  case- 
ation, softening,  cyst  formation,  haemorrhage,  and,  after  the  disease  has 
broken  through  the  skin,  ulceration  and  slouorhincj. 

Sarcoma  of  bone  originates  either  from  the  periosteum  or  from  the 
medullary  cavity.  The  latter,  or  myelogenic  sarcoma,  is  characterised 
by  having  a  greater  number  of  giant  cells.  As  long  as  the  central 
(myelogenic)  sarcoma  of  bone  possesses  a  closed  capsule  the  prognosis 
is  favourable,  but  otherwise  it  is  extremely  bad.  Out  of  twelve  pa- 
tients with  sarcomata  of  the  long  bones  which  were  removed  with  the 
knife,  six  died  from  recurrences,  which  in  two  of  the  remaining  six. 


§128.] 


THE   DIFFERENT  VARIETIES  OF  TUMOURS. 


767 


cases  soon  afterwards  necessitated  secondary  operations.  According 
to  the  shape  of  the  cells  and  the  structure  of  the  sarcoma  the  follow- 
ing different  forms  are  distinguished,  which  of  course  often  merge  into 
and  combine  with  one  another  to  a  greater  or  less  extent : 

1.  The  round-celled  variety  occurs  as  the  small-  and  large-celled  sarcoma. 
The  small  rouud-celled  sarcoma  (Fig.  42.'})  is  made  iij)  of  cells  which  resemble 
wjiite  blood-corpuscles,  and  as  a  rule  grows  rapidly,  forming  a  soft  tumour, 
wliich  on  section  appears  white,  and  when  squeezed  gives  out  a  milky  fluid. 
It  consists  of  I'ound  cells,  blood-vessels,  and  generally  of  a  very  small  amount 
of  a  fibrous,  granular,  or  homogeneous  stroma.  In  some  cases  it  has  a  pro- 
nounced alveolar  sti'ucture.  and  then  resembles  gland  tissue  or  carcinonia — 
i.  e.,  the  cells,  or  rather  grovips  of  cells,  are  divided  off  by  connective-tissue 
septa  (alveolar  sarcoma.  Fig.  425).  The  small  round-celled  sarcomata  are 
usually  very  malignant  in  character;  they  destroy  the  surrounding  tissues, 
forming  metastases  and  running  a  coui'se  similar  to  carcinoma  (§  129).  The 
most  common  locations  for  this  sarcoma  are  connective  tissue,  muscle,  fa.scia, 
periosteum,  bone,  lymph  glands,  etc. 

"^  The  Imye  round-celled  sarcoma  (Fig.  426),  although  it  is  not  quite  so 
malignant  as  the  small-celled  and  does  not  grow  as  rapidly,  is  very  similar 
to^  the  latter  in  its  clinical 
course.      It    also    occasion- 
ally  possesses    an  alveolar 
structure. 

2.  The  spindle-celled  sar- 
coma usually  consists  of 
cells  which  are  for  the  rnost 
part  long,  thin,  and  spindle- 
shaped,  lying  close  together 
(Fig.  427),  with  or  without  a 
variable  amount  of  homo- 
geneous or  fibrous  inter- 
cellular substance.  If  the 
latter  is  fibrous  and  abun- 
dant, the  tumour  is  called  a 
fibro-sarcoma. 

3.  The  giant-celled  sar- 
coma is  characterised  by  the 
presence  of  a  great  number 

of  very  large,  polynuclear,  round,  or  polymorphous  cells  (Fig.  428),  and  origi- 
nates most  commonly  in  bone  marrow  (myelogenic  osteo-sarcoma).  Giant 
cells  are  also  occasionally  found  in  the  round  and  spindle-celled  sarcomata, 
but  not  by  any  means  in  such  quantities  as  in  the  true  giant-celled  neoplasm. 

4.  Stellate  or  reticular-celled  sarcomata  are  most  commonly  encountered 
in  myxomata  and  myxo-cbondromata  which  are  combined  with  sarcoma. 
The  stellate  or  reticular  cells,  with  their  interlocking  processes,  are  usually 
embedded  in  a  soft,  gelatinous,  mucoid  intermediary  substance. 

5.  In  many  sarc"omata  cells  of  all  varieties  of  shapes  are  found  together 
(sarcoma  with  polymorphous  cells.  Fig.  424). 


Fig.  427.  — Cells  from  a 
spindle  -  celled  sarcoma 
of  the  thigh,     x  300. 


Fig.  428.— Cells  from  a 
myelogenic  giant-celled 
sarcoma  of  the  lower 
jaw.      X  300. 


768 


TUMOURS. 


6.  The  alveolar  sarcoma  (Fig.  425)  which  was  mentioned  above  is  made 
up  of  mononuclear  and  polvnuclear  cells,  as  a  rule  about  as  large  as  average- 
sized  pavement  epithelial  cells,  which  lie  singly  or  in  groups  in  a  fibrous,  less 
often  in  a  homogeneous  intermediary  substance.  A  characteristic  feature  of 
this  variety  is  that  the  cells,  contrary  to  carcinoma,  are  closely  united  to  the 
connective-tissue  stroma,  and  cannot  be  easily  separated  from  the  fibrous 
meshes.  Although  this  forms  the  means  of  distinguishing  the  alveolar  sar- 
coma from  carcinoma,  yet  sections  of  the  two  tumours  under  the  microscope 
often  present  such  similar  pictures  that  it  is  very  difficult  to  recognise  one 
from  the  other. 

7.  The  plexiform  angeio-sarcoma  (Waldeyer)  is  to  be  looked  upon  as  an 
angeioma  with  a  sarcomatous  growth  of  the  walls  of  the  vessels;  it  originates 
mainly  by  growth  of  the  endothelial  cells  which  lie  nest  the  adveutitia  of 
both  the  lymph  and  blood-vessels  CFig.  429).     These  cell  growths  surround 

the  walls  of  the  vessels  like  a  sheath, 

•  »ut.i;^^'=^5^-=»'^^'^y.^^^i        and,  as  a  growth  of  the  inner  en- 

;^^^■r.,}.<^■\y.,.^^■^2'■rr:n^■^v^^p^.^y?=^rtr^^        dothelial  cells  also  takes  place,  the 

•':-■•"';.  vV-'V  --ov^  lumen  of  the  blood  or  lymph  ves- 

V  VJ  V  ; /_  ;.  vVv;-  ,  \.,r- v:  •  -v  sel  in  question  may  finally  become 

\':-i---r:^-.y'-':'-''y-\-:'r'^  entu*ely  occluded.     The   reticulated 

v\-i-';-x-v    ■Vv^~;^;;■^■^^^•■-?^^  anastomosing  filaments  and  tubules 

r'-'; '-^^v^'-'^':  ■ '-^  of  the  cells  usually  lie  in  fibrillar 

>f.r.;      ■      .  :  -•';}^^  connective  tissue,  and  as  a  result  of 

:'•■;,    ■    /:,:,::  .  :  .  .  '    "  hyaline  degeneration  of  the  Avails  of 

■  --   ,;    .  ^-         ;.     .-  _  the  vessel  hyaline  tubules  are  formed 

-         -  -V  ?,:'v\.  having  cells  in  their  interiors,  or  the 

■y  .■'.'.'-' y'^r:  latter  ai'e  so  narrowed  by  the  hya- 

;<-•:,-.'  line  degeneration  that  only  hyaline 

_^...._>^,-_.vv5^y;.^=£i-XA;^^^^^^^^  branching  cords,  bulbs,  or  spherules 

"" '~    -^^^^i''-'''     *  "■  %'  without  cells  are  found.     Occasion- 

FiG.  429.— Plexiform  an?eio-sarcoma,  or  rather,  ally  the  hyaline  degeneration  attacks 

endothelioma,  of  the  thigh     The  anasto-  primarilv  the  cells  in  the  tubules,  SO 

mo.sing  groups  ot  cells  are  derived  in  this  \  ■,      \        t  -,  ■, 

instance'  from  proliferation  of  the  endo-  that  the  hvalme  cords  are  surround- 

thelium  of  the  Ivmph  vessels;  they  sur-  ^j  ^^^.  ^^^^  which  have  not  yet   be- 
round  the  latter  like  a  sheath.     In  some  "  t       mi  i       -j? 

places  the  groups  of  cells,  or  rather  en-  come    degenerated.     The   plexiform 

&othelium,  are  in  solid  masses,  while  in  augio-sarcoma  is  reallv  an  endothe- 
others  they  have  undergone  degeneration.  '^  - 

X  30.  liosarcoma  or  endothelioma,  and  on 

account  of  the  hyaline  cylinders  this 
tumour  was  once  called  a  cylindroma.  The  endothelioma  arises  in  some 
cases  from  the  endothelium  of  the  blood-vessels,  and  in  others  from  the  endo- 
thelioma of  the  lymphatics  or  connective  tissue.  Kiister  rightly  called  atten- 
tion to  the  fact  that  there  are  haemorrhagic  sarcomata  or  angeio-sarcomata 
(endotheliomata)  which  show  extensive  degeneration  of  the  walls  of  vessels 
— i.  e.,  growth  of  endothelial  cells  and  hyaline  degeneration — before  a  tumour 
nodule  has  become  developed ;  they  lead  to  haematomata  without  macroscop- 
ically  visible  sarcoma  tissue.  In  other  cases  such  haematomata  are  followed, 
months  after,  perhaps,  by  remarkably  malignant  sarcomata.  The  plexiform 
angeiosarcoma  oj*  endothelioma  is  anatomically  easily  mistaken  for  carci- 
noma, and  runs  a  similai'  course — i.  e.,  it  is  a  markedly  malignant  tumour. 


^^128.]  THE    DIFKERENT   VARIETIES  OP  TUMOURS.  769 

recurs  after  extirpation,  and  causes  at  a  comparatively  early  period  an  infec- 
tion of  the  nearest  lymph  glands  and  metastases.  Hence  .some  authors  have 
designated  the  malignant  endothelioma  as  endothelial  cancer.  Some  of  the 
endotheliomata  should,  however,  not  he  counted  among  true  neoplasms  on 
account  of  their  diffuse  development,  but  should  i-ather  he  assigned  to  the 
infectious  tumours. 

The  .va)it]io)na  or  xanthelasma,  a  sulphur-yellow  or  brownish-yellow  pig- 
uientiition  of  the  skin,  is,  according  to  De  Viucentiis,  Touton  and  others,  an 
endothelioma  in  which  fat  has  been  deposited  (endothelioma  lipomatodes) ; 
it  grows  from  the  endothelium  of  the  lymphatic  ves.sels,  and  occurs  in  a  flat 
(xanthoma  planum)  and  nodular  (xanthoma  tuberosum)  form,  especially  on 
the  eyelids,  though  occasionally  it  has  a  multiple  character,  api^earing  on 
different  parts  of  the  body,  particularly  where  there  are  folds  of  skin  (flexor 
side  of  joints,  axilla,  neck,  etc.).  Now  and  then  the  eruption  occurs  more  or 
less  suddenly — in  the  course  of  diabetes,  for  example  (xanthoma  diabeticum) 
—at  other  times  symmetrically,  probably  from  tropho-neurotic  disturbances. 
Occasionally  it  changes  into  sarcoma  or  fibroma  (sarco-xanthoma,  fibro- 
xanthoma). 

The  villous  sarcoma,  the  so-called  cholesteatoma,  which  may  be  encoun- 
tered on  the  meninges  of  the  brain,  probably  owes  its  origin  likewise  to 
growth  of  the  endothelial  cells  of  the  vessels,  or  rather  of  the  cells  of  their 
sheaths. 

Perhaps  the  psammoma  of  the  brain  and  orbit  described  by  Virchow  also 
belongs  to  the  endotheliomata.  They  are  characterised  by  the  presence  of 
lai'ge  amounts  of  lime  concretions  similar  to  the  "brain  sand"  normally 
present  in  the  hypophysis  cerebri.  Such  concretions  are  met  with  in  sar- 
coma, fibi'oma,  and  myxoma,  and,  according  to  Billroth,  are  to  be  regarded 
as  calcified  bundles  of  endothelial  cells  which  are  attached  to  the  blood- 
vessels, though  Yii'chow  thinks  they  are  also  the  result  of  the  calcification  of 
connective  tissue. 

The  melanosarcoma  (pigmented  sarcoma)  is  characterised  by  the  presence 
of  a  brown  or  black  pigment  which  is  almost  always  deposited  in  the  cells, 
less  often  in  the  intercellular  substance  and  walls  of  the  vessels.  On  section 
the  melanomata  are  brown,  or,  if  the  pigmentation  is  excessive,  black  in 
colour.  They  are  among  the  most  malignant  tumours,  their  growth  being 
sometimes  very  rapid  and  the  number  of  metastases  considerable  (see  Fig. 
430).  They  are  most  likely  to  develop  in  places  where  pigment  is  already 
present — as  in  freckles  or  pigmented  warts,  for  example  (Fig.  430) — and  most 
commonly  begin  on  the  extremities.  The  origin  of  the  pigment  is  doubtful. 
According  to  Gussenbauer,  it  is  foj'med  from  thf;  red  blood-corpuscles  of  the 
thrombosed  vessels,  while  others  think  that  it  is  not  identical  with  the  pig- 
ment resulting  from  haemorrhages,  but  may  be  due  to  a  special  activity  of 
the  cells  (Birch-Hirschfeld).  Schmidt  considers  the  pigment  to  be  haema- 
togenous  in  nature,  having  passed  the  haemosiderin  stage  and  parted  with  its 
iron  reaction. 

Terrillon  observed,  in  a  case  of  melanosis  which  ran  a  rapidly  fatal  course, 
an  increase  in  the  number  of  white  corpuscles  in  the  blood  and  a  large  num- 
ber of  "  black  bodies."  Melanuria  is  encountered  in  rare  instances  of  multi- 
ple melanoma,  and  Zeller  found  vai'iable  amounts  of  hydrobilirubin  and. 
49 


770 


TUMOURS. 


melanin  in  the  dark-browh  but  otherwise  perfectly  clear  urine.     The  urine 
_in  melanosis,  when  first  passed,  is  clear,  but  if  allowed  to  stand  becomes 
black,  and  at  times  almost  the  colour  of  ink. 

The  question  of  the  transmissibility  of  melanoma,  which  has  been  experi- 
mentally studied  by  Lanz,  has  not  yet  been  definitely  settled,  but  I,  person- 


FiG.  430.— Melanoma  of  the  skin  (man  seventy-four  years  old)  originating  in  a  pigmented  wart 
upon  the  back ;  within  six  months  over  one  hundred  pigmented  spots  and  tumors  formed 
upon  tlie  skin.  Numerous  melanosarcomata  of  the  pleura,  lungs,  pericardium,  liver,  kid- 
neys, and  retroperitoneal  glands  were  found  (Liicke). 

ally,  do  not  doubt  that  it,  like  sarcoma  and  carcinoma,  is  capable  of  develop- 
ing from  inoculation,  as  shown  by  the  following  remarkable  instance  of  this 
which  was  observed  by  Lanz :  The  latter  injected  into  a  guinea-pig  a  certain 
amount  of  an  infusion  of  melanotic  cutaneous  nodules,  melanotic  brain, 
liver,  and  spleen.  The  animal  died  a  month  and  a  half  after  the  injection, 
and  the  autopsy  showed  collections  of  pigment  in  many  different  parts  of  the 
body  (skin,  subcutaneous  tissue,  muscles,  peritoneum,  spleen,  liver,  kidneys, 
etc.).  In  this  case  the  pigment  must  have  been  formed  vrithin  the  body,  as 
only  very  little  of  the  colouring  matter  was  injected. 

The  chloroma  is  a  pale,  grass,  or  brownish  green  round-celled  sarcoma, 
which,  according  to  the  observations  that  have  been  made  up  to  the  present 
time,  originates  in  the  periosteum  of  the  bones  of  the  face  and  cranium,  and 
gives  rise  to  metastatic  green  nodules  in  various  organs,  especially  the  liver 
and  kidneys.  According  to  Huber,  the  green  colour  is  due  to  small,  very 
refractive  granules,  which  are  fotxnd  in  the  cells  and  which  give  the  micro- 
chemical  reaction  of  fat.  The  chloroma  is  also  characterised  by  the  presence 
of  an  abnormally  large  amount  of  chlorine. 

We  have  already  dwelt  sufficiently  upon  the  course  and  prognosis 
of  sarcoma  when  discussing  its  different  varieties.  The  duration  of 
the  disease  depends  in  general  upon  the  importance  of  the  organ  in- 
volved.    The  sarcoma  of  the  brain  is  the  most  rapidly  fatal,  and  may 


§12!».]  TIIK    KIMTIIKLlAIi   TUMOURS.  771 

cause  deatli  in  one  and  a  half  to  two  months/  Sarcomata  of  the  medi- 
astinum arc  likewise  very  malignant,  and  may  prove  fatal  in  a  few 
months  by  suffocation  or  paralysis  of  the  lieart.  The  prognosis  is 
most  favourable  in  the  sarcomata  of  the  skin,  wliich  can  be  easily  extir- 
pated, and  of  the  extremities  in  case  the  tumours  are  removed  early 
enough  by  operative  means.  We  have  already  mentioned  that  sarco- 
ma, especially  of  the  skin,  can  be  made  to  disappear  permanently  by 
the  inoculation  of  erysipelas.  Among  important  diagnostic  factors, 
besides  the  above-described  general  characteristics  of  sarcoma,  are  its 
*  location  and  the  age  of  the  patient.  Its  favourite  location  is  in  mus- 
cle, periosteum,  bone,  nerves,  glands  (lymph  glands,  parotid,  testicle, 
mamma),  and  it  not  infrequently  develops  after  an  injury.  As  regards 
''age,  sarcoma  is  most  common  in  middle  life,  and  less  so  in  childhood 
and  old  age.     It  is  usually  a  painless  tumour. 

The  general  rule  for  treatment  is  to  remove  the  neoplasm  as  soon 
as  possible.  In  suitable  cases  of  encapsulated,  myelogenic  giant-celled 
sarcoma  of  bone  the  anterior  half  only  of  the  bony  capsule  may  be 
removed  by  means  of  the  hammer  and  chisel  or  the  saw,  and  the  tu- 
mour carefully  scraped  out  with  a  sharp  spoon.  In  inoperable  cases 
the  inoculation  of  erysipelas  may  be  tried.  Burns  has  observed  three 
permanent  cures  in  five  cases  of  this  kind,  and  Coley  published  an 
account  of  nine  cases  with  four  cures.  Among  the  latter  was  a  very 
remarkable  case  of  Bull's  :  Round-celled  sarcoma  of  the  neck,  with  five 
recurrences  in  three  years  ;  the  entire  removal  was  impossible  in  the 
last  operation,  and  a  wound  twelve  and  a  half  by  five  centimetres  re- 
sulted, which  soon  became  filled  up  witli  masses  of  sarcoma  tissue. 
Fourteen  days  later  two  attacks  of  erysipelas  took  place,  whereupon 
the  wound  rapidly  cicatrised.  Seven  years  afterwards  the  cure  was 
found  by  Bull  and  Coley  to  be  perfect.  Langenbuch  has  also  published 
an  instance  of  a  great  number  of  recurrent  sarcomata  of  the  skin  which 
were  caused  to  disappear  by  this  means.  One  must,  however,  con- 
stantly bear  in  mind  that  the  patient  may  die  as  a  result  of  the  inocu- 
lation of  erysipelas,  and  hence  it  is  one's  duty  to  warn  the  patient 
or  his  friends  of  the  danger  before  this  procedure  is  adopted.  The 
various  other  methods  of  treatment  of  sarcoma  are  described  in  the 
Special  Surgery,  and  in  connection  with  the  treatment  of  tumours  in 
general. 

)V  .  §  129.  The    Epithelial    Tumours. — The  epithelial  tumours   include 
the  papilloma,  the  epithelioma,  the  adenoma,  and  the  carcinoma. 

I.  Papilloma. — The  papilloma  results  from  hyperplasia  of  the  epi- 
thelial layer  of  the  skin  and  mucous  membranes,  with  a  corresponding 
new  growth  of  connective  tissue  and  blood-vessels.    It  is  really  a  mixed 


772 


TUMOURS. 


Fig.  431.— Warty  hyper- 
trophy of  the  scalp  oc- 
curring in  a  woman 
twenty  years  of  age 
(Billroth). 


tumour  consisting  of  newly  formed  connective  tissue  and  ejDitheliura. 

A  distinction  is  made  between  a  hard  and  a  soft  papilloma. 
'    The  hard,  horny  papillomata  include,  in  the  first  place,  warts  (ver- 

ruc£e),  which  are  the  well-known  growths  of  the  papillae  of  the  skin 
and  epidermis,  about  the  size  of  a  bean  or  a  pea. 
They  are  essentially  a  product  of  an  overgrowth 
of  the  epidermis,  which  becomes  horny,  and  often 
occur  in  great  numbers  without  any  known  cause, 
especially  on  the  hands,  though  in  rare  instances 
a  diiiuse  warty  hypertrophy  of  the  cutis  has  been 
observed  on  the  scalp  (see  Fig.  431).  Mention 
should  also  be  made  of  the  onychoma  (hyper- 
trophy of  the  nails),  calluses  (clavi)  resulting  from 
a  circumscribed  hyperplasia  of  the  epidermis,  and 
the  cutaneous  horns  (cornea  cutanea),  which  are 
excrescences  on  the  skin  due  to  a  new  growth  of 
horny  epithelial  cells  (true  epitheliomata).  The 
cutaneous  horns  occasionally  originate  from  the 

sebaceous  glands  or  from  open  atheromata  (sebaceous  cysts).     They  are 

most^ommpn  on  the  forehead  and  nose  in  old  people.  Brinton  has 
collected  fifteen  cases  of  cutaneous  horn  of  the 
penis,  besides  one  that  came  under  his  own  ob- 
servation. They  sometimes  occur  in  great  num- 
bers (Fig.  432),  not  infrequently  being  curved, 
and  may  attain  a  length  of  from  twelve  to  sixteen 
centimetres  or  more  (see  Special  Surgery).  It 
should  be  noted  that  occasionally  benign  cutane- 
ous horns  which  consist  only  of  horny  epithelial 
cells  change  into  carcinomata. 

In  this  category  belong  also  the  tumour-like 
thickenings  of  the  epidermis  called  keratomata, 
which  are  most  commonly  found  on  the  sole  of. 
the  foot  and  the  palm  of  the  hand,  and  are  not 
infrequently  inherited  by  all  the  branches  of  a 
family  for  many  generations  (Unna).  They  re- 
sult from  a  thickening  of  the  epidermis,  though 
the  whole  cutis  also  takes  part  in  the  hyperplasia. 
They  often  change  into  real  cutaneous  horns  or 
become  combined  with  other  new  growths  like  an- 
geiomata  (angeio-keratoraa).  Unna  recommends 
for  their  treatment  the    use    of   a   ten-per-cent. 

ethereal  solution  of  salicylic  acid,  or  the  latter  made  into  a  plaster. 


Fig.  432.— Multiple  cutane- 
ous horns,  from  twelve 
to  sixteen  centimetres 
in  lentrth,  on  various 
portions  of  the  body  of 
a  seventeen -year -old 
girl  (Bathge). 


§129.]  THE   EPITIIKLIAL   TUMOURS.  773 

lelitlivosis  (from  Ix^^'i^  fi^^O  is  a  scaly  tliickeiiing  of  the  epidermis, 
usually  congenital,  over  the  entire  surface _pf_tlie  body.  Hystricismus 
(from  varpL^.  hedgehog)  is  a  disease  in  which  there  is  a  formation  of 
thorn-like  excrescences  on  the  skin,  due  to  hypertrophy  of  the  ]^apillse 
and  the  epidermis.     It  is  likewise,  as  a  rule,  congenital  in  origin. 

^  The  soft  papilloma  is  characterised  by  a  soft  stroma,  a  marked  vas- 
cularity, and  a  very  moderate  growth  of  epithelium,  which  does  not 
become  horny.  They  occur  ou  the  skin  and  mucous  membranes,  gen- 
erally of  the  bladder,  rectum,  and  uterus.  The  cauliflower  excrescence 
of  the  vaginal  portion  of  the  cervix  is  a  soft  papilloma.  In  the  rec- 
tum, uterus,  and  in  other  mucous  membranes,  the  soft  papilloma  forms 
growths  which  are  analogous  to  the  above-mentioned  mucous  polyps. 
The  polyps  which  are  covered  with  epidermis,  rete  Malpighii,  cutis,  and 
liair,  and  occur  in  the  pharynx,  for  example,  originate,  according  to 
Arnold,  from  strayed  embryonic  cells  and  probably  belong  to  the  tera- 
tmnata.  The  soft  papillomata  not  infrequently  change  into  sarcoma 
and  carcinoma.  The  condyloma  acuminatum  found  on  the  mucous 
membrane  of  the  vulva,  vagina  and  penis  is  also  a  soft  papilloma; 
the  broad  condyloma  (condyloma  latum)  is  a  papillary  growth  with  a 
broad  base,  and  often  occurs  about  the  anus  in  syphilis. 

The  various  kinds  of  papilloma  should  be  treated  according  to  the 
general  rules  already  laid  down.  Warts  should  be  removed  by  cauter 
isation  with  red,  fuming  nitric  acid  (not  chemically  pure),  after  paring 
oS  the  epidermis  with  a  knife.  They  are  then  usually  cast  off  on  the 
fifth  or  sixth  day,  or,  if  not,  they  may  have  to  be  cauterised  again. 
Repeated  applications  of  salicylic  or  iodoform  collodion  with  a  brush, 
as  well  as  of  a  paste  made  witli  arsenic,  are  also  exceedingly  serviceable. 
By  the  use  of  these  medicaments  the  wart  gradually  drops  off  in  the 
form  of  a  dried-up  eschar.  The  same  treatment  may  be  used  for  cal- 
luses and  corns,  though  they  can  be  removed  more  simply  by  the  knife 
after  softening  them  in  salt  water. 

Molluscum  Contagiosum  or  Epithelioma  MoUuscum. — Authorities  diflFer 
widely  in  their  views  as  to  the  nature  of  molluscum  contagiosum.  It  is  a 
pecuHar  skin  disease  in  which  there  is  a  development  of  numerous  nodules, 
varying  in  size  from  that  of  a  pea  to  that  of  a  hazel-nut  or  larger,  generally 
located  on  the  uncovered  parts  of  the  body  and  on  the  genitals.  The  small 
tumours  are  epithelial  in  character,  and  are  said  by  Hebra  to  be  caused  by  an 
accumulation  of  cells  in  a  sebaceous  gland,  while  Virchow  thinks  the  growth 
of  epithelial  cells  begins  in  the  hair  follicles,  and  Bizzozero,  in  the  interpapil- 
lary  portions  of  the  rete  Malpighii.  They  contain  characteristic  bodies,  partly 
free  and  partly  enclosed  in  cells  which  resemble  swollen  starch,  and  which, 
according  to  Leber,  are  degenerated  epithelial  cells,  although  Klebs  and  Bol- 
linger maintain  that  they  are  parasitic  (psorosperms,  coccidia).     The  disease 


774  TUMOURS. 

is  contagious,  atid  not  infrequently  occurs  in  the  form  of  epidemics,  especially 
in  children's  asylums.  Isolated  cases  are  rarely  met  with.  The  treatment 
consists  in  simply  pressing  out  the  small  tumours  with  the  finger  nail ;  the 
larger  ones  may  require  the  use  of  the  sharp  spoon.  Healing  takes  place 
without  the  formation  of  a  cicatrix. 

II.  Adenoma  {Glaiidular  Tumour). — The  adenomata  correspond  iu 
their  structure  to  that  of  glands  (Fig.  433),  but  the  term  does  not  in- 
clude simple  hypertrophy  of  the  latter,  being  used  to  designate  only 
the  true  new  growths  which  are  separated  from  the  surrounding  tissues 
in  the  form  of  circumscribed  nodular  tumours.  Even  adenomatous  de- 
generation of  an  entire  organ  can  be  easily  distinguished  from  a  general 
glandular  hyperplasia.  The  adenomata  form  both  hard  and  soft 
tumours.  Microscopically,  a  distinction  is  made  between  tubulous  and 
acinous  or  alveolar  adenoma.  They  are  very  often  combined  with  the 
formation  of  cysts.  •  The  adenoma  is  in  itself  not  malignant,  but  it  fre- 
quently changes  into  a  destructive  form — i,  e.,  it  becomes  a  carcinoma, 
in  that  the  growing  tubules  penetrate  the  surrounding  parts,  take  on  an 
atypical  growth,  destroy  the  neighbouring  tissues,  and,  by  involving  the 

lymphatics  and  blood-vessels,  give  rise 

•,  .^vV7•>?;v.:^'i;•v/;A,^';^<?5i):e^,^^^-^:^  to   metastases.     The   commencement 

V  #      ''■''/^■'' '  '^'''  ■:';■/ ,    ,5^^^^      ^^  ^  change  like  this  from  adenoma 

:^\.-'-^^-'      '•;;;:  ;  0       ■'       '';r;V  i"^"?         to  carcinoma  has  been  called  adenoid. 

':S  ,:   %..;.■..'''::■       ^g  '  :'..  '  ;;>;;_     Tlicrc  arc,  however,  inalignant  adeno- 

',  I,.,  ■'■■■■■:■■■■  /,.■/:•  mata,  which  remain  true  adenomata, 

^i'/:'.: ;      :^'' % '!l\  ;-^      with  a  distinct  separation  of  the  glan- 

vnU''    -^^  ;-  't  \''''!-:::      dular  epithelium  from  the  stroma,  but 

;>/■  ■:"'  /      which  nevertheless  cause  local  destruc- 

^;).ii^       tion  of  tissue  and  give  rise  to  metas- 

^       tases.    The  adenoma  of  the  rectum  is 

•%'''''•■'•;''';;;.,     ::':^'  '%\:i-r'!:^'^        an   example   of    this    variety.      The 

'  -^'i^' «  --  adenoma  is  found  in  various  glandular 

Fm.  433.-A^denoma^mamm^  al^  organs,  in  the  skin  (sebaceous  glands, 

sweat  glands),  in  the  respiratory  and 
digestive  tracts,  in  the  genital  organs,  the  mamma,  thyroid,  and  salivary 
glands,  liver,  kidneys,  etc. 

The  treatment  of  adenoma  consists  in  prompt  extirpation  of  the 
tumour,  as  it  is  to  be  looked  upon  as  an  early  stage  of  carcinoma,  into 
which  it  frequently  develops.  "With  reference  to  the  technique  of  the 
operation  for  removal  of  adenoma  of  the  thyroid  (goitre)  and  of  lapa- 
rotomy for  removal  of  ovarian  adenoma,  particulars  will  be  found  in 
the  Special  Surgery. 

III.  Carcinoma  {Cancer). — A  carcinoma  originates  from  the  atyp- 


§  129.] 


THE  EPITHELIAL  TUMOURS. 


77i 


ical  growth  of  epithelial  cells,  the  latter  forming  the  main  part  of  the 
tjimour,  though  every  atypical  growth  of  epithelium  is  not  cancer.  In 
intlammatory  processes  and  in  the  healing  of  wounds,  an  aty|)ical  growtli 
of  epithelial  cells  takes  place  in  the  form  of  cylinders  or  hulbs,  but  their 
growth  is  limited  and  they  do  not  infiltrate  and  destroy  the  surround- 
ing tissues.  It  is  (piite  different  with  carcinoma.  Here  the  epithelial 
cells  keep  on  growing  unhindered  ;  they  infiltrate  the  surrounding  tis- 
sues in  the  form  of  cell  nests,  displacing  and  destroying  them.  The 
cellular  cylinders  and  nests,  which  are  made  up  of  proliferating  epi- 
thelial cells,  lie  embedded  in  a  partly  old  and  partly  new  formed  con- 
nective-tissue stroma  (Fig.  434).     As  a  result  of  the  unimpeded  growth 


Fig.  434. — Carcinoma  mammae  simplex. 
X  200. 


Fig.  435. — Section  through  a  com- 
mencing embolic  cancer  in  a 
liver  capillary  resulting  from 
an  adeno  -  carcinoma  of  the 
stomach  (Ziegler).     x  300. 


of  the  carcinoma,  or  rather  of  the  groups  of  epithelial  cells,  the  latter 
invade  the  lymph  and  blood  vessels  and  produce,  by  means  of  trans- 
ported living  cancer  cells,  secondary  nodules  in  the  nearest  lymph 
glands,  and  later  in  the  various  internal  organs  (Fig.  435).  This  power 
of  forming  metastases — in  other  words,  of  causing  a  general  infection 
oi  the  body — is  characteristic  of  cancer.  As  regards  the  development 
of  metastases  in  the  lymph  glands,  it  has  been  shown  that  the  epithe- 
lial cells  which  make  their  way  through  the  afferent  lymphatics  into 
the  lymph  sinuses  multiply  by  caryocinesis ;  that  they,  by  their  con- 
tinuous growth,  iTiechanically  displace  the  glandular  tissue  ;  and  that 
endothelial  cells  and  lymph  cells  do  not  change  into  cancer  cells.  The 
general  cancerous  infection  can  lead  to  such  extreme  exhaustion  that 
the  patient  succivnbs  to  the  cancerous  cachexia. 

In  the  skin  the  carcinoma  arises  from  the  cells  of  the  rete   Mal- 
pighii  or  from  the  cutaneous  glands ;  an  infiltration  of  the  corium  with 


re 


TUMOURS. 


epithelial  cells  gradually  takes  place,  tlie  cells  being  collected  in  single 
groups,  cylinders,  or  nests  which  lie  in  a  partly  old  and  partly  new 
formed  connective-tissue  stroma.  In  the  glands  a  proliferation  of  the 
glandular  epithelium  first  takes  place,  forming  an  adenoma  ;  then  these 
proliferated  cells  invade  the  tissue  surrounding  the  lobes  of  the  glands, 
where  they  continue  to  grow  unimpeded.  The  shape  of  the  proliferated 
epithelial  or  cancer  cells  is  not  constant,  but  depends  upon  the  l9cation 
of  the  cancer.  The  cells  of  an  epithelioma  of  the  skin  correspond  in 
general  to  those  of  the  rete  Malpighii,  while  in  a  carcinoma  of  the 
stomach  they  have  a  cylindrical  form,  etc.  Retrograde  metamorphoses 
are  very  common  in  carcinoma  because  the  nutrition  of  the  great  num- 
bers of  cancer  cells  is  insufficient.  Hence  fatty,  mucoid,  colloid,  or 
cystic  degeneration  as  well  as  calcification  are  of  frequent  occurrence. 
The  degenerative  changes  in  the  central  portions  of  a  carcinoma  and 
the  adhesion  of  the  integument  often  give  rise  to  an  umbilicated  draw- 
ing in  or  depression  of  the  skin.  Superficial  carcinomata,  especially 
those  which  involve  the  skin,  mucous  membranes,  or  mamma,  are 
extremely  apt  to  break  down  and  form  extensive   sloughing,    punched- 


Fig.  436. — Large  ulcerating  careiuouia  of  tliu 
lower  jaw  and  cheek  occurring  in  a  pa- 
tient sutt'eriug  frona  lupus  (Esinareh). 


Fig.  437. — Pronounced  destruction 
of  the  face  by  an  epithelioma  of 
the  skin  (Billroth). 


out  cancerous  ulcers  (Figs.  436,  437).  Bleeding  not  infrequently  takes 
place,  manifesting  itself  in  the  form  of  circumscribed  hiemorrhages  or 
blood  cysts,  or,  in  other  cases,  a  carcinoma  may  by  degrees  erode  a  large 
vessel,  and  thus  suddenly  lead  to  a  profuse  loss  of  blood,  which  may 
prove  fatal. 

Occasionally   a  primary  carcinoma  is  found  in  a  multiple  form. 


t^  12!).]  TIIH]    KPITHELIAL   TUMOURS.  777 

St'liiiimiell)iis('li  has  colU'cti'd  these  rare  cases  from  literature  showinir 
that  multiple  carciiiomata  of  the  skin  are  the  most  common,  and  may 
develop  from  a  soot  or  tar  eczema,  from  senile  sehorrluea  and  xero- 
derma pigmentosum,  ulcer  of  the  leg,  etc.  In  some  instances  they 
probably  originate  l)y  inoculation  from  one  })art  of  the  body  to  an- 
other, though  in  addition  to  these  multiple  carcinomata  of  inocula- 
tion others  occur  which,  according  to  Schinunelbusch,  are  to  be  re- 
garded as  independent  tumours  appearing  simultaneously.  Mandy 
has  reported  a  carcinoma  of  both  ears  which  came  under  observation 
in  Bruns's  clinic. 

The  following  different  varieties  of  carcinoma  have  been  described. 

1.  Flat  Epithelial  Cancer  or  Epithelioma.— The  epithelioma  of  the  skin, 
or  cancroid,  appears  in  the  form  of  diffuse  thickenings  or  nodular,  warty,  often 
ulcerating-,  elevations.  On  section,  the  alveolar  structure  can  usually  be  seen 
with  the  naked  eye  and  the  epithelial  nests  or  cylinders  can  be  squeezed  out 
or  scraped  from  the  cut  surface  with  the  knife.  Some  epitheliomata  remain 
superficial,  while  others  grow  into  the  deeper  parts.  The  superficial  variety, 
the  cancroid  or  ulcus  rodens,  as  it  is  called,  which  is  more  flat  than  the  other, 
arises  mainly  from  the  rete  Malpighii,  while  the  growth  having  deeper  at- 
tachments take  its  origin  to  a  greater  extent  from  the  sebaceous  glands. 

Epitheliomata  also  develop  on  mucous  membranes  that  have  a  pavement 
epithelium  (mouth,  pharynx,  oesophagus,  vagina,  uterus,  bladder). 

2.  Cylindrical-celled  Carcinoma. — The  carcinoma  with  cylindrical  cells  is 
found  particularly  in  the  mucous  membrane  of  the  digestive  tract  and  uterus; 
it  has  a  soft  consistency  and  is  very  likely  to  undergo  a  mucoid  degenera- 
tion. 

3.  Carcinoma  u-ith  Gland  Cells  {Carcinoma  Glandulare). — This  is  found 
in  various  glandular  organs  (mamma,  liver,  salivary  glands,  kidneys,  testicles^ 
etc.),  and  varies  microscopically  according  to  the  organ  affected. 

4.  Other  Varieties  of  Carcinoma. — According  to  the  shape,  consistency, 
and  other  properties  of  the  cancer  the  following  varieties  may  be  difPeren- 
tiated.  The  scirrhus  is  a  very  hard,  tough  carcinoma  with  small  and  few 
cancer  cell  nests  lying  in  a  dense  stroma.  The  soft  carcinoma  (carcinoma 
medullare)  is  the  opposite  of  the  scirrhus,  being  rich  in  cells  and  having  a 
soft  stroma.  The  pigmented  or  melano-carcinoma,  like  the  melano-sarcoma, 
is  a  brown  or  black  tumour,  which  is,  however,  much  less  common  than  the 
latter.     The  pigment  is  likewise  situated  in  the  cells. 

The  so-called  giant-celled  carcinoma  is  in  some  instances  made  up  of  true 
giant  cells,  while  in  others,  the  increase  in  the  size  of  the  cells  is  due  to 
mucoid  or  dropsical  degeneration. 

The  colloid  cancer  (carcinoma  gelatinosum)  occurs  especially  in  the  intes- 
tine and  breast,  where  it  forms  a  transparent  gelatinous  tumour  as  a  result  of 
the  mucoid  or  gelatinous  degeneration  of  the  cell-nests.  The  carcinoma 
myxomatodes  originates  either  from  the  mucoid  degeneration  of  the  stroma 
and  often  of  the  cancer  cells,  or  from  the  combination  of  a  myxoma  with  a 
carcinoma   (myxo-carcinoma).      Occasionally   colloid   degeneration   of  the 


Y78  TCMOURS. 

cancer  cells  gives  rise  to  homogeneous  spherical  bodies  which  are  found  in 
the  cancer  nests. 

The  external  appearance  of  carcinoma  is  variable.  Most  commonly  there 
is  a  formation  of  circumscribed  nodules ;  less  often  the  disease  takes  the  form 
of  a  more  diffuse,  superficial  infiltration  and  induration,  or  of  papillary- 
growths  with  large,  branching  papillae  (villous  cancer— e.  g.,  of  the  bladder). 
Occasionally  the  skin,  as  in  the  region  of  the  mamma,  becomes  diffusely 
diseased,  as  hard  as  a  board,  and  infiltrated  by  a  great  number  of  small  and 
large  nodules  (cancer  en  cuirasse). 

Etiology  of  Carcinoma.— Local  irritations  of  a  mechanical  and  chem- 
ical character  are  very  important  factors  in  the  production  of  a  carcino- 
ma. Hence  one  is  most  likely  to  develop  in  those  parts  of  the  body  wliere 
mechanical  and  chemical  irritations  most  commonly  occur,  as  in  the  skin, 
lips,  mouth,  oesophagus,  and  in  other  parts  of  the  digestive  tract  where 
normally  narrow  places  exist,  such  as,  for  example,  the  cjesophagus  at  the 
point  where  it  passes  through  the  diaphragm,  the  cardiac  and  pyloric 
regions  of  the  stomach,  the  flexura  sigmqidea,  the  rectum  near  the 
sphincter  tertius,  and  the  anus.  In  nien,  cancers  of  the  skin,  lips 
(almost  always  the  lower  lip),  mouth,  and  rectum  are  the  most  com- 
mon ;  while  in  women  the  glandular  carcinomata  predominate,  and 
those  of  the  mamma  and  the  uterus  are  especially  frequent.  Carci- 
noma of  the  stomach  is  equally  common  in  women  and  men,  and  is 
very  likely  to  develop  from  a  cicatrised  gastric  ulcer.  The  epitheli- 
omata  of  the  lips,  especially  the  lower  lip  in  men,  have  been  ascribed  to 
smoking,  to  frequent  irritation  from  unskilful  shaving,  etc.,  and  the 
epitheliomata  of  the  tongue  and  mucous  membrane  of  the  inside  of 
the  mouth  to  the  irritation  produced  by  smoking  and  chewing  tobacco, 
or  by  the  sharp  edges  of  the  teeth.  The  epitheliomata  of  the  scrotum, 
observed  in  cliimney-sweeps  and  workers  in  tar  and  paraffine,  are  ex- 
plainable on  the  same  principle.  Analogous  irritating  chemical  sub- 
stances are  present  in  soot,  tar,  and  paraffine,  just  as  in  tobacco-smoke, 
tobacco-juice,  and  tobacco-ashes — i.  e.,  various  products  of  dry  distilla- 
tion, especially  carbolic  acid.  These  irritating  substances  become  de- 
posited in  the  skin  of  the  scrotum,  and  sometimes  give  rise  to  cancer. 
I  observed  in  a  worker  in  paraffine  who  had  a  characteristic  chronic 
paraffine  dermatitis  with  the  formation  of  scabs  and  pustules  on  the 
hands  and  forearms,  the  development  of  a  typical  carcinoma  with 
metastases  at  the  site  of  one  of  the  scabs.  Fig.  438  shows  the  hand 
of  this  patient,  who  finally  died  of  general  carcinosis.  Two  years  pre- 
viously I  had  removed  from  the  same  man  a  paraffine  epithelioma  of 
the  scrotum,  which  did  not  recur.  Chronic  inflammations  in  various 
parts  of  the  body  often  give  rise  to  carcinoma.     Cancer  will  also  be 


giocj.j  THE   EPITHELIAL  TUMOURS.  779 

found  in  conjunction  with  benign  neoplasms,  like  fibroma,  atheroma, 
cutaneous  horns,  etc.,  and  in  cicatrices.  According  to  different  authors, 
its  development  is  favoured  by  a  too  plentiful  meat  diet,  as  the  inhab- 
itants of  southern  countries,  who  live  largely  on  vegetable  food,  and  the 

herbivorous  animals  are  said,  as  compared 
with  the  carnivora,  to  suffer  very  seldom 
from  this  disease.  A  predisposition  to 
carcinoma  often  appears  to  be  inherited. 
It  is  essentially  a  disease  of  advanced  life. 
At  this  period  a  slowly  increasing  atrophy 
of  the  stroma,  in  a  certain  sense,  takes 
place,  causing  the  skin,  for  instance,  to  be- 
come shrivelled  and  thin,  and  rendering 
it  easier  for  the  epithelium  to  make  its  way 
into  the  stroma  as  a  result  of  mechanical 
or  chemical  irritations.  A  "  boundary 
war,"  as  it  were,  begins  between  epithelium 
and  connective  tissue,  which  in  carcinoma 
ends  in  a  victorious  entrance  of  the  epithe- 
lium into  the  less  resistant  stroma. 
■  ^'  "What  is  the    cause  of   the    unlimited 

;     f  energy  and  power  of  growth  possessed  by 

P     carcinoma?     Hansemann  attempted  to  an- 
swer this  question  in  the  following  way : 
.:    v  AVhile  it  is  an  established  fact  under  nor- 

mal conditions  that  in  the  indirect  nuclear 


Fig.  438.— Hand  of  a  worker  in  par-     division  the  chromatin  or  nuclcar  fibrils 

artine.  showing  chronic  derma-        t    .  ^        •    ,  ,^  i'-j 

titis  with  a  formation  of  pus-  divide  mto  exactly  cqual  -  sized  groups, 
growths; clSma'of^hSS  Hansemaun  found  that  in  malignant  epi- 
arm  starting  from  one  of  these     thelial  tumours  (carciuoma)  a  division  often 

inflamed  spots;   amputatio  an-  ^  ■'  — 

tibrachii  and  death  from  gen-     took  place  into  two  Unequal  groups ;  and 

eral  carcinosis. .  .  . 

he  thinks  that  this  asymmetrical  nuclear 
division,  which  belongs  only  to  the  malignant  epithelial  growths,  is 
due  to  the  fact  that  the  cell  eliminates  certain  parts  of  its  protoplasm 
in  the  same  way  that  the  ovum,  by  expelling  the  directing  or  polar 
globules,  frees  itself  of  certain  elements  that  are  present  in  too  large 
quantities.  In  this  way  the  cancer  cells  attain  an  independence  like 
that  of  the  ovum,  and  to  this  is  due  their  energy  of  growth  and  power 
of  further  development  as  metastases  in  different  parts  of  the  body. 

Importance  of  Micro-organisms  in  the  Etiology  of  Carcinoma.— Scheuer- 
len  (Deutsche  med.  Wochenschi-ift,  1887,  No.  48)  attempted  to  make  pure 
cultures  of  specific  bacilli  and  spores  from  a  carcinoma,  and  inoculate  them 


780 


TUMOURS. 


into  animals.  He  used  for  his  experiments  ten  mammary  carcinomata,  and 
made  on  the  average  twenty  inoculations  for  each  case,  among  which  there 
were  always  at  least  seven  successful  ones.  The  microscopic  examination  of 
the  pure  cultures  showed,  in  addition  to  bacilli  from  1-5  to  2'5  micromilli- 
metres  in  length  and  0'5  micromillimetre  in  breadth,  a  number  of  almost  as 
large  ovoid,  translucent,  and  greenish -coloured  bodies  (spores).  The  bacilli 
and  spores  have  a  special  kind  of  self -locomotion ;  the  former  can  be  stained 
by  all  methods  and  immediately  decolourised  by  alcohol.  The  spores  can  be 
stained  in  the  same  way  as  tubercle  bacilli.  Scheuerlen  could  not  find  with 
certainty  bacilli  or  spores  in  sections  of  carcinomatous  organs,  but  he  did 
find  them  in  the  cancer  juice,  mostly  outside  the  cancer  cells.  Pure  cultures 
of  cancer  bacilli  grow  best  upon  agar,  potato,  infusion  of  meat  peptone,  or 
cabbage,  and  more  slowly  upon  gelatine.  In  agar  a  streaky  cloud  is  de- 
veloped along  the  line  of  puncture,  similar  to  the  one  caused  by  the  bacilli 
of  mouse  septicaemia.  By  injection  of  media  containing  cancer  bacilli  into 
the  mammary  glands  of  six  bitches,  hard  cancer  nodules  were  produced  from 
which  pure  cultures  of  characteristic  bacilli  and  spores  could  be  obtained. 

Other  authorities,  such  as  PfeiflPer  and  Sanarelli,  have  also  found  Scheu- 
erlen's  bacilli  in  carcinoma,  but  attempts  at  inoculation  proved  entirely 
unsuccessful,  axxd  the  majority  of  winters  are  of  the  opinion  that  there  is  at 
present  no  ground  for  considering  the  questionable  bacilli  to  be  the  cause  of 
cancer.  They  are  much  more  inclined  to  think  that  it  is  merely  an  innocent, 
accidental  saprophyte.  Pfeiffer  maintains  that  the  bacillus  is  identical  with 
the  proteus  mirabilis. 

Schill  found  in  sections  and  in  the  juice  of  carcinoma  and  sarcoma  little 
rods  containing  two  dots,  both  ends  of  which  appeared,  after  staining  by 
Gram's  method,  as  small  points  of  a  deep  violet  colour,  which  were  joined 
by  a  transparent  thread.     Besides  these  a  mould-fungus  was  present. 

Some  interesting  investigations  have  been  made  by  Thoma,  who  found 
in  carcinomata  of  the  rectum,  the  stomach,  and  the  breast  peculiar  unicellu- 
lar sti'uctures  within  the  cell  nuclei,  having  a  diameter  of  from  four  to  fifteen 
micromillimetres,  spherical  or  oval  in  shape,  or  moi'e  like  a  whetstone,  and 
consisting  of  protoplasm  and  a  nucleus.  He  is  inclined  to  think  that  these 
bodies  are  encapsulated  coccidia.  Whether  they  are  to  be  looked  upon  as  the 
cause  of  carcinoma  cannot,  as  Thoma  himself  says,  be  decided  until  further 
exact  tests  have  been  made.  Many  other  investigators  have  seen  similar 
bodies  in  the  nuclei  or  protoplasm  of  epithelial  cells  in  carcinoma,  some 
looking  upon  them  as  psorosperms,  and  others  as  altered  and  degenerated 
epithelial  cells.  The  question  whether  protozoa  really  are  present  in  carci- 
noma has  been  discussed  very  fully  of  late,  and  the  matter  is  one  of  great 
interest.  But  the  occurrence  of  coccidia  in  carcinoma  has  become  more  and 
more  doubtful  recently,  and  they  are  thought  by  many  to  be  products  of  the 
degeneration  of  cells  (Le  Dentu,  Karg,  author).  Schiitz  thinks  it  very  prob- 
able that  some  of  the  bodies  originate  from  the  red  blood-cells.  It  is  evident 
that  we  have  to  deal  here  with  morphologically  and  genetically  different 
forms  of  cells  as  well  as  of  cellular  and  nuclear  changes,  including  Altmann's 
cell  granula. 

The  fuchsine  bodies  described  by  Russell  and  others  as  characteristic  of 
carcinoma  and  thought  to  be  blastomycetes  are,  according  to  Klein,  Altmann,, 


%\2d.]  THE   KPITIIELIAL  TUMOURS.  781 

and  Karg-  very  larjife  cell  granules.     The  parasitic  nature  of  carcinoma  is  at 
present  still  an  open  question. 

The  Transmissibiliti/  of  Carcinoma. — The  question  whether  carcinoma 
is  transmissible  or  not  is  of  the  greatest  importance  as  regards  its  etiology. 
That  it  is  has,  in  fact,  been  experimentally  proved  in  the  case  of  mice  and 
rats  by  Novinsky  and  Morau,  who  also  succeeded  in  causing  metastases  in 
the  internal  oi'gans  of  the  former  anitiial.  It  has  also  been  noted  that  carci- 
noma is  occasionally  transferred  from  one  part  to  another  of  the  same  body, 
or  from  one  person  to  another.  Halin  cut  skin  grafts  from  some  of  the  nu- 
merous disseminated  cutaneous  nodules  of  a  cancer  existing  on  the  thorax  of 
a  woman  and  planted  them  on  other  portions  of  her  body,  and  found  that 
they  went  on  growing  and  developed  into  similar  cancers.  Cornil  and 
Frank  have  likewise  seen  successful  inoculations  of  carcinoma  in  man.  It 
has  repeatedly  been  observed  that  malignant  tumours  (carcinoma  and  sarco- 
ma) have  resulted  from  a  simple  transference  of  living  tumour  cells  during 
an  operation,  and  hence  this  means  of  infection  may  occasionally  be  the 
cause  of  recurrences  after  the  extirpation  of  such  a  neoplasm,  Billroth  saw 
an  isolated  carcinoma  form  in  the  cicatrix  in  the  overlying  abdominal  wall 
after  extirpation  of  a  similar  growth  (which  was  not  adherent  to  the  sur- 
rounding parts)  from  the  pylorus.  Becker  and  Czerny  have  also  noticed  in- 
stances of  cancerous  inoculation  of  a  cicatrix  following  an  operation.  Berg- 
mann  saw  a  carcinoma  of  the  upper  and  lower  lips  at  exactly  opposite  points, 
a  circumstance  which  made  it  probable  that  one  was  the  cause  of  the  other. 
There  are  many  similar  cases  recoi'ded,  all  of  which  indicate  that  carcinoma 
originates  from  infection  by  contact,  and  may  develop  in  a  person  who  comes 
into  close  relations  with  another  who  has  the  disease ;  husbands,  for  exam- 
ple, have  been  known  to  acqiiire  one  of  the  penis  from  wives  with  a  cancer 
of  the  uterus  (Czerny,  Tross,  etc.).  This  transmissibility  possessed  by  carci- 
noma does  not  prove,  of  course,  that  the  poison  of  cancer  depends  upon  mi- 
cro-organisms; on  the  contrary,  it  seems  very  probable  that  the  transmission, 
like  the  metastases,  is  accomplished  by  the  living  cancer  cells. 

Course,  Prognosis,  and  Diagnosis  of  Carcinoma. — Carcinoma  runs  a 
chronic  course  extending  over  months  and  years.  Its  varying  energy 
of  growth  and  its  location  are  factors  of  great  importance  in  determin- 
ing how  rapidly  or  slowly  the  disease  will  progress.  In  rare  instances 
a  more  or  less  acute  general  carcinosis  takes  place,  causing,  in  a  few 
weeks,  metastases  and  marked  cancerous  cachexia.  The  latter  is  very 
much  increased  by  rapid  growth  of  the  primary  and  secondary  cancer 
nodules,  by  ulceration  and  sloughing,  by  stenoses  that  interfere  with 
the  entrance  of  air  or  food,  by  disturbances  of  digestion,  etc.  Ulcera- 
tion is  especially  prominent  in  epitheliomata  of  the  skin.  Cancerous 
ulcers  are,  as  a  rule,  irregular  in  form,  and  their  edges  and  bases,  as 
well  as  the  surrounding  tissue,  are  hard  and  indurated.  The  superficial 
ulcerating  epithelioma  of  the  skin,  the  so-called  cancroid  or  ulcus 
rodens,  runs  comparatively  the  most  favoural)le  course,  in  that  it 
spreads   slowly   over   the   surface,  has   less   tendency  to  involve   the 


782  TUMOURS. 

deeper  parts,  and  only  leads  late  in  its  course  to  infection  of  the  near- 
est lymph  glands. 

According  to  Klemperer,  the  metabolism  of  cancerous  individuals 
is  characterised  by  a  pronounced  destruction  of  albumen,  the  viscera 
undergoing  fatty  degeneration  and  the  blood  showing  a  marked  diminu- 
tion in  its  percentage  of  carbonic  acid  ;  and  hence  he  infers  that  carci- 
noma causes  a  systemic  intoxication  by  means  of  certain  poisonous  sub- 
stances— a  conclusion  which  is  not  accepted  by  Minkowski.  According 
to  Mijller,  the  cancerous  cachexia  resulting  from  the  increased  destruc- 
tion of  albumen,  the  diminution  of  the  chlorides  in  the  urine,  and  the 
loss  of  weight,  is  similar  to  the  febrile  processes  and  cachexiae  present 
in  long-continued  malaria,  leucaemia,  and  pernicious  anaemia.  The  cause 
of  the  abnormal  destruction  of  albumen  in  cancerous  individuals  prob- 
ably lies  in  the  poisonous  action  of  the  ])roducts  of  metabolism  of  the 
carcinoma.  As  a  result  of  the  accumulation  of  these  products  of  me- 
tabolism and  of  the  insufficiency  of  the  kidneys,  symptoms  of  coma 
earcinomatosum  and  death  may  supervene  (see  pages  Y43,  744). 

The  prognosis  of  cancer  is,  as  we  have  already  clearly  stated,  very 
unfavourable.  Complete  cures  are  rare,  even  when  the  carcinomata  are 
extirpated  very  early  in  their  course.  As  a  rule,  one  recurrence  fol- 
lows another  until  the  patient  succumbs  to  general  carcinosis  or  exhaus- 
tion. We  make  a  distinction,  based  upon  their  mode  of  origin,  between 
continuous  and  regional  recurrences ;  the  former  spring  from  portions 
of  the  primary  tumour  which  were  left  behind  at  the  time  of  the  opera- 
tion, while  the  latter  (regional  recurrences)  are  to  be  looked  upon  as 
independent  new  tumours  in  the  cicatrix  or  its  vicinity.  The  second 
kind  sometimes  make  their  appearance  only  after  the  lapse  of  years. 
All  recurrences  which  occur  later  than  two  years  after  the  operation 
should  be  considered,  according  to  Snow,  new  independent  tumours 
resulting  from  new  injurious  agencies. 

The  diagnosis  of  carcinoma  is  in  general  not  difficult  if  what  has 
been  said  be  borne  in  mind.  A  differential  diagnosis  may  have  to  be 
made  from  tubercular  and  syphilitic  growths.  A  careful  microscopic 
examination  of  an  excised  portion  of  the  tumour  wnll  usually  clear  up 
any  uncertainty.  If  syphilis  is  suspected,  antisyphilitic  treatment  should 
be  begun  (iodide  of  potassium,  mercury,  etc.),  and  when  the  latter  dis- 
ease is  present  such  a  method  of  treatment  will  be  successful,  but  not 
in  cases  of  carcinoma. 

Treatment  of  Carcinoma. — The  treatment  of  carcinoma  consists  in  as 
early  an  extirpation  as  possible.  During  the  later  stages  an  attempt 
should  at  least  be  made  to  check  its  course  and  improve  the  general 
condition  of  the  patient.     In  extirpation  with  the  knife  as  much  of  the 


§12!).]  THE  EPITHELIAL  TUMOURS.  783 

healthy  tissue  as  can  be  spared  should  be  included,  so  as  to  leave  no 
tumour  cells  behind.  The  nearest  lymph  glands  nmst  always  be 
thought  of;  thus,  in  every  amputation  of  the  breast,  for  example,  the 
axilla  should  be  opened  and  the  glands  and  all  the  fat  removed,  even 
thouirh  no  enlargement  of  the  former  can  be  felt  from  without.  After 
the  axilla  has  been  cut  into,  slightly  enlarged  lymph  glands  are  often 
found  in  cases  where  they  were  not  suspected.  Complete  cures  some- 
times result  from  an  early,  careful  extirpation  of  a  carcinoma,  and  if 
no  recurrence  appears  within  one  and  a  half  to  two  years  the  patient  is 
to  be  regarded  as  probably  entirely  freed  from  his  disease.  I  have, 
however,  occasionally  seen  recurrence  take  place  three  years  after  the 
tirst  operation.  One  generally  occurs  sooner  or  later,  and  after  extir- 
pation of  this,  the  carcinoma  very  frequently  reappears  in  a  still  shorter 
time,  making  it  seem  in  many  cases  as  though  recurrences  were  hastened 
and  increased  in  virulency  by  each  succeeding  operation. 

The  different  methods  of  operation  for  carcinoma  with  the  knife,  gal- 
vano-cautery,  thermo-cautery,  etc.,  are  described  in  the  chapters  on  gen- 
eral surgical  technique,  and  the  extirpation  of  carcinomata  in  different 
parts  of  the  body — the  skin,  breast,  mouth,  stomach,  intestine,  uterus, 
etc. — is  described  in  the  Special  Surgery. 

The  treatment  of  inoperable  carcinomata  is  symptomatic.  Accord- 
ing to  the  nature  of  the  case,  a  trial  may  be  made  of  the  various  methods 
already  mentioned  in  connection  with  the  treatment  of  tumours  in  gen- 
eral. These  include,  in  addition  to  a  general  strengthening  regimen, 
parenchymatous  injections,  the  arsenic  treatment,  and  circumcision 
with  the  thermo-cautery  in  order  to  diminish  the  growth,  pain,  and 
final  sloughing  of  the  carcinoma.  In  sloughing  cancers,  use  may  be 
made  of  the  sharp  spoon,  thermo-cautery,  and  dressings  filled  with  deo- 
dorizing substances,  such  as  acetate  of  aluminium,  carbolic  acid,  bichlo- 
ride of  mercury,  iodoform,  and  naphthaline.  Narcotics  in  the  form  of 
subcutaneous  injections  of  morphine  are  often  indispensable.  The 
inoculation  of  erysipelas  has  already  been  spoken  of  on  page  771.  It  is 
frequently  necessary  to  perform  an  operation  for  the  treatment  of  the 
sequelae  of  an  inoperable  carcinoma ;  a  tracheotomy  may  be  required, 
for  example,  in  carcinomatous  stenoses  of  the  larynx,  or  the  formation 
of  an  artificial  anus  in  carcinoma  of  the  intestine.  Whether  the 
growth  of  the  disease  is  influenced  by  the  transplantation  upon  it  of 
healthy  skin  (Goldmann)  cannot  as  yet  be  definitely  decided. 

Amongst  the  medicinal  preparations  that  have  recently  been  well 
spoken  of,  the  following  should  be  mentioned :  Mosetig-Moorhof 
recommended  parenchymatous  injections  of  aniline  dyes  (methyl  violet 
or  pyoktannin  1  to  500  aq.  dest.),  but  I  have  seen  no  good  results  from 


784 


TUMOURS. 


its  use.  Clay  (Birmingham)  speaks  well  of  the  action  of  turpentine  (in 
the  form  of  the  essence  made  by  Southall  and  Barclay  in  Birmingham, 
two  teaspoonfuls  three  or  four  times  a  day,  with  pills  of  sulphur  and 
sulphate  of  copper,  etc.  ;  also  local  injections  into  the  tumour).  Stroh- 
binder  uses  parenchymatous  injections  of  tannic  acid  into  the  carcino- 
matous growths  (one  hypodermic  syi-ingeful  a  day).  Glycerine  and 
resorcin  liave  also  been  used  locally,  decoctum  Zittmanni  (decoctum 
sarsaparillffi  compositum)  internally,  and  chalk,  powdered  oyster-shells, 
and  condurango-bark  both  internally  and  locally — all  of  which  are  prob- 
ably useless.  Esmarch  and  others  have  recommended  for  cancer  pa- 
tients a  diet  consisting  of  but  little  nitrogenous  matter. 

§    130.  Cysts — Atheromata,  Teratomata,  Cyst-formation  in  Different 
Tumours. — The  formation  of  cysts  takes  place,  as  we  have  already  said, 


Fig.  4-39. — Cyslo-sarcoma  of  tlie 
femur  (Busch). 


Fig.  440.  — Proliferatincj  fMlliouhir  dental  cyst 
of  the  lower  .jaw  iQ  a  pesisant  thirty-two 
years  of  age  (Bryk). 


in  many  different  kinds  of  tumours,  especially  adenoma  (cysto-adeno- 
ma),  fibroma  (cysto-fibroma),  and  sarcoma  (cysto-sarcoma),  as  a  result  of 
softening. 

The  proliferating  cystoma  of  the  ovaries,  kidneys,  or  mammae,  in 
which  a  new  production  of  cysts  takes  place,  belongs  to  the  class  of  the 
true  cystic  tumours.  But,  in  the  main,  these  proliferating  cysts  are 
adenomata ;  a  proliferation  of  cells  first  occurs,  and,  secondarily,  the 
formation  of  cysts  as  a  result  of  mucoid  and  colloid  degeneration  of 
the  cells.      This  continues,  until  finally  very  large  tumours  are  de- 


§130.]  CYSTS— ATIIEROMATA,   TERATOMATA.  785 

veloped,  particularly  in  the  ovaries.  Cystic  goitres  also  begin  as 
adenomata. 

Bone  cysts  are,  as  a  rule,  either  enchondromata,  fibi-oinata,  or  sarco- 
mata, which  have  undergone  cystic  degeneration  (Fig.  439),  or  true 
proliferating  cystic  tumours.  To  the  latter  belongs  that  cystic  degen- 
eration which  often  simultaneously  aftacks  all  the  bones  of  the  body, 
and  is  perhaps  to  be  regarded  as  a  constitutional  disease.  Bramann 
found  a  multiple  formation  of  cysts  in  a  great  number  of  the  bones  of 
a  woman  thirty-four  years  old,  who  had  osteomalacia.  Many  bone 
cysts  are  probably  due  to  inllammatory  processes  or  haemorrhages 
(Schlange).  The  cysts  of  the  jaw  and  teeth  (Fig.  440)  arise  either 
from  the  periosteum  or  from  the  dental  follicles  as  a  result  of  disturb- 
ances of  development.  Here,  also,  the  proliferation  of  cells  takes  place 
first,  and  then  a  progressive  formation  of  cysts  follows.  A  large  num- 
ber of  cysts,  originating  in  a  great  variety  of  ways,  are  congenital ; 
these  have  been  described  very  fully  by  Lannelongue  and  Archard. 
Other  cysts  are  due  to  parasites,  such  as  echinococcus  and  cysticercus 
cellulosae,  and  are  found  in  various  organs  of  the  body. 

The  contents  of  the  cysts  are  serous,  mucous,  or  bloody.  A  dis- 
tinction is  made  between  simple  and  compound  or  multilocular  cysts. 
The  interior  of  the  latter  is  divided  off  by  septa,  and,  in  some  in- 
stances, new  cysts  form  in  the  walls  of  the  old  ones. 

The  retention  cysts  do  not  belong  to  the  true  tumours,  as  in  these 
cases  an  abnormal  new  growth  of  cells  does  not  occur,  but  only  an 
accumulation  of  secretion.  With  Virchow,  we  divide  the  retention 
cysts  into  (1)  mucous  cysts,  (2)  follicular  cysts,  and  (3)  retention  cysts, 
starting  in  the  excretory  duct  or  the  acini  of  large  glands.  Mucous 
cysts,  which  result  from  the  retention  of  the  secretion  of  the  mucous 
glands,  are  found  especially  in  the  mucous  membrane  of  the  lips,  the 
cheeks,  the  antrum  Highmori,  the  respiratory  and  digestive  tract,  the 
vagina,  the  uterus,  etc.  The  follicular  cysts  include  the  comedones, 
those  well-known  little  spots  in  the  skin,  often  of  a  black  colour,  which 
are  plugs  or  secretion  in  the  hair  follicles,  and  the  milium  resulting 
from  a  similar  accumulation  of  secretion  in  the  sebaceous  glands.  The 
atheromata  or  sebaceous  cysts  are  retention  cysts  of  the  hair  follicles. 
The  latter  continue  to  form  their  secretion,  and  consequently  the  sac 
becomes  more  and  more  tense ;  and  thus  are  developed  in  the  skin  the 
well-known  tumours  which  vary  in  size  from  that  of  a  small  pea  to  that 
of  a  fist  or  a  child's  head,  and  contain  epidermis,  fat,  and  crystals  of 
cholesterin.  A  second  variety  of  atheroma  is  situated  not  in  the  skin, 
but  deeper  down  in  the  subcutaneous  tissue.     These  deep  subcutaneous 

atheromata  are  probably  the  result  of  separated  embryonic  remnants 

50 


786 


TUMOURS. 


of  skin  tissue  wliicli  contain  sebaceous  glands  or  groups  of  epithelium 
belonging  to  the  epidermis.  In  the  latter  case  they  might  be  called 
epidermoids  (Franke).  Franke  thinks  that  atheromata  are  not  reten- 
tion cysts  of  the  skin  follicles,  but  represent  true  new  growths  which 
have  sprung  from  embryonic  cells.  The  atheromata  sometimes  grad- 
ually break  through  the  integument,  and  become  complicated  by  in- 
flammation, suppuration,  or  even  epithelioma  (Fig.  441).  Hence  ex- 
tirpation of  atheromata  is  always  indicated.  Cutaneous  horns  occa- 
sionally develop  from  open  atheromata  with  fistulse. 

Among  the  retention  cysts  which  arise  from  the  excretory  ducts  or 
acini  of  large  glands  may  be  mentioned  the  retention  cysts  of  the  liver, 

the  mamma,  and  the  kidney ;  also  th,e  so- 
called  ranula  under  the  tongue  near  the 
frenulum  resulting  from  the  closure  of 
the  excretory  ducts  of  the  submaxillary 
and  sublingual  glands,  and  particularly  of 
the  Blandin-Nuhn  glands — two  mucous 
glands  situated  near  the  tip  of  the  tongue. 
Cysts  are,  moreover,  found  in  structures 
which  do  not  persist  after  the  birth  of  the 
foetus  ;  examples  of  these  are  branchiogenic 
cysts  of  the  neck,  cysts  of  the  urachus,  etc. 
We  have  already  mentioned  the  occur- 
rence of  blood  and  lymph  cysts  due  to  a 
gradual  dilatation  of  blood-  and  lymph- 
vessels. 

By  cholesteatoma  is  meant  either  an 
atheroma  or  a  dermoid  cyst,  with  charac- 
teristic, often  silky  white  contents  which  are 
made  up  of  fat,  cholesterin,  and  groups  of  cells  which  shine  like  mother- 
of-pearl.  The  cholesteatomata  are  found  especially  in  the  brain  and  its 
meninges ;  also  in  the  ovaries,  in  the  subcutaneous  cellular  tissue,  and 
in  bone  (petrous  portion  of  the  temporal).  According  to  Eppinger  and 
others,  the  cholesteatomata  are  essentially  endotheliomata  (see  page  768). 
Glaeser  examined  one  which  was  found  on  the  base  of  the  brain,  and 
came  to  the  conclusion  that  the  cells  of  the  cholesteatoma  develop 
from  the  endothelia  of  the  lymph  spaces  of  the  arachnoid  by  growth 
and  concentric  division.  Kuhn  is  disposed  to  think  that  the  cholestea- 
tomata of  the  ear  are  principally  congenital  in  origin.  Politzer  found 
small  roundish  bodies  in  the  mucous  membrane  of  the  ear  which  in- 
crease in  size  and  lead  to  the  formation  of  these  tumours.  The  sup- 
puration and  sloughing  which  accompany  cholesteatomata  of  the  ear 


Fio.  441. 


Woman  fifty-nine  years 
with  atheromata  of  the 
hairy  portion  of  the  scalp;  a 
typical  carcinoma  developed  in 
a  cyst  which  suppurated  on  the 
top  of  her  head. 


^  lao.]  CYSTS— ATIIEROMATA.  TERATOMATA.  787 

arc  secondary  coiulitions,  and  not,  as  irabcrniann  tliinks,  the  cause  of 
their  development.  These  sequela;  lead  not  infrecjuently  in  cholestea- 
toniata  of  the  ear  to  death  of  the  patient ;  and  hence  Kuhn  emphasises 
the  necessity  of  a  radical  removal  by  osteotomy,  if  it  is  required,  of 
the  portion  of  the  hone  in  (juestion  (mastoid  process).  The  etiology 
of  cholesteatomata  of  the  middle  ear  and  the  meatus  is  proljably  com- 
plex ;  some  of  the  cases  are  certainly  endotheliomata,  while  others  are 
the  result  of  a  simple  ])rolif oration  of  epithelial  cells,  or  a  change  of 
epithelial  cells  into  epidermis.  The  etiology  of  cholesteatomata  has  an 
extremely  interesting  hearing  upon  the  etiology  of  tumours  in  general, 
showing,  as  it  does,  that  tumours  can  arise  from  the  cells  of  the  meso- 
derm which  correspond  exactly  to  those  that  originate  from  epithelium. 

The  treatment  of  cysts  depends  largely  upon  their  location  and 
their  cause ;  it  consists  in  extirpation,  puncture,  incision,  parenchyma- 
tous injection  of  various  fluids,  such  as  absolute  alcohol  with  or  with- 
out tincture  of  iodine  (see  page  715,  Treatment  of  Tumours  in  Gen- 
eral), etc.  The  treatment  of  cysts  of  the  different  parts"  of  the  body  is 
described  in  the  Text-Book  on  Special  Surgery.  The  extirpation  of 
smaller  atheromata  is  best  accomplished  by  introducing  a  probe  or  a 
small  instrument  shaped  like  a  spatula,  or  a  pair  of  Cooper's  scissors, 
into  the  cutaneous  incision,  freeing  the  atheroma  on  all  sides,  and 
finally  taking  out  the  uninjured  cyst  with  its  capsule  in  toio.  Care 
must  be  taken  to  always  remove  the  whole  of  the  atheroma,  which 
should  not  be  opened  at  the  time  the  cutaneous  incision  is  made ;  this 
may  be  done  by  cutting  through  the  skin  first  at  the  base  of  the  tu- 
mour, and  after  separating  the  latter  from  the  surrounding  parts  with 
a  probe,  enlarging  the  original  incision  with  scissors  sufficiently  to 
permit  the  loosened  cyst  to  be  enucleated. 

Teratomata  are  congenital  tumours  or  malformations  which  are 
made  up  of  a  great  variety  of  tissues.  They  include  both  the  double 
monstrosities,  in  which  one  embryo  is  rudimentary  and  united  to  the 
other,  and  malformations  which  have  taken  place  in  a  single  foetus. 
All  sorts  of  structures  have  been  found  in  congenital  tumours  and 
cysts.  Kiimmel  discovered  in  a  congenital  coccygeal  neoplasm  a  body 
that  resemljled  an  eye  wdiich  was  similar  to  one  found  by  Marchand 
and  Baumgarten  in  an  ovarian  cyst. 

The  dermoid  cysts  also  belong  in  this  class  ;  they  have  an  inner  wall 
which  is  analogous  to  the  skin,  and  may  occur  in  organs  where  skin  is 
not  normally  present.  They  are  most  commonly  found  in  the  ovary, 
and  also  in  the  peritonaeum,  neck,  orbits,  nose,  and  in  the  sacral  and 
coccygeal  regions.  The  wall  of  the  cyst  consists,  as  we  have  said,  of 
epidermis  and  corium,  with  sebaceous  glands,  hair  follicles,  and  less 


788  TUMOURS. 

often  sweat  glands.  The  contents  usually  consist  of  a  fatty,  yellowish 
or  whitish,  greasy  mass,  together  with  hairs,  cartilage,  bone,  and  even 
teeth.  In  very  rare  cases,  brain,  nerve,  and  muscle  tissue  or  structures 
resembling  extremities  have  been  found.  Occasionally  the  contents  are 
oily  (oil  cysts).  Kocher  and  Streit  have  laid  emphasis  upon  a  pecul- 
iarity possessed  by  these  tumours — when  not  filled  too  full — of  retain- 
ing for  a  considerable  length  of  time  any  change  of  form  which  is  given 
them.  This  is  due  to  their  homogeneous  cement-like  contents.  If  epi- 
thelial cells  and  masses  of  fat  are  mixed  with  a  large  amount  of  hair,  a 
peculiar  crepitation  may  be  felt  on  palpation  of  the  tumour  (Kocher). 
The  dermoid  tumours  develop  from  stray  cutaneous  cells  which  have 
been  inverted,  as  in  the  closure  of  embryonic  clefts.  At  the  same  time 
cells  of  the  entoderm  may  become  displaced  or  separated. 

Polypous  appendages  are  sometimes  found  upon  different  parts  of 
the  surface  of  the  body.  They  are  to  be  looked  upon  as  abnormal  dis- 
placements of  tissue  or  malformations  depending  upon  an  imperfect 
closure  of  embryonic  clefts.  Such  tumours  or  cutaneous  appendages, 
occasionally  containing  cartilage,  are  found  in  the  vicinity  of  the  lines 
of  closure  of  the  dorsal  or  ventral  clefts,  or  near  the  face,  ears,  neck, 
anal  region,  or  the  rliaphe  of  the  periuaeum  (Chiari). 


INDEX. 


Acetabulum*  wandering  of  the,  674,  675, 

Acetal  as  anresthctic,  43. 

Acetate  of  aliiminiuin,  158. 

Acetic  ether,  39. 

Aceto-tartrate  of  ahuiiiiiinn),  159. 

Acne,  518. 

Acromegaly,  650. 

Acromicria,  651. 

Actinomyces,  355. 

Actinomycosis,  441. 

diagnosis  and  prognosis  of,  446. 

occurrence  in  animals,  443. 

occurrence  in  man,  444. 

treatment  of,  447. 
Acufilopressure,  94. 
Acupressure,  94. 
Adenoid,  774. 
Adenoma,  774. 
Air  cushions,  303. 

Air,  entrance  of,  into  veins,  60,  453. 
Alcohol  dressings,  168. 
Aldehyde,  39. 
Alkaloids,  cadaver,  364. 
Alumnol,  170. 
Amoebae,  377. 

Amputation,  general  technique  of,  and  in- 
dications for,  113,  476. 

after-treatment  of,  134. 

artificial  limbs  after,  137. 

mortality  of,  137. 

sequelas  of,  134. 

subperiosteal,  133. 
Amputation  in  cases  of  fracture,  603. 
Amputation  knives,  115. 
Amputation  neuroma,  136. 
Amputation  stump,  conical,  135. 
Amputation  with  scraping  out  the  medulla, 

616. 
Anaemia,  artificial,  48.     (See  also   Ischae- 

mia.) 
Ana?sthesia,  15. 

local,  43. 
Anaesthetics,  15-45. 
Anatomical  tubercle,  380. 
Anchylosis,  696. 
Aneurysms,  533. 

diagnosis  and  prognosis  of,  537. 

symptoms  of,  536. 

treatment  of,  537. 

varieties  of,  533-535. 


Angeioma,  755. 

Angeio-keratoma,  773. 

Angeio-sarcoma,  757. 

Aniline  dyes  as  antiseptic,  169. 

Anomalies  of  granulating  wounds,  521. 

Anthrax,  381. 

in  animals,  386. 

attenuation  of   virulence   of  bacilli  of, 
384. 

bacillus  of,  383. 

etiology  of.  383. 

immunity  from,  385. 

in  man,  386. 

occurrence  and  origin  of,  384. 

stain  of  bacilli  of,  386. 
Antisepsis,  3. 
Antiseptic  dressings,  146. 
Antiseptics,  153. 
Aorta,  congenital  stenosis  of,  531. 

ligation  of,  396. 
Aphthae  epizooticae,  394. 
Apparatus  for  gymnastics.  815. 
Apparatus  for  permanent  irrigation,  179. 
Argentum  nitricum,  79. 
Aristol,  167. 

Arm,  bandages  for,  190. 
Army  surgery,  737. 
Arrow  poison  of  Indians,  405. 
Arsenic  paste,  80. 
Arteries,  530. 

aneurysms  of,  543. 

digital  compression  of,  47. 

diseases  of,  530. 

hjemorrhage  from,  86. 

inflammation  of,  339. 

ligation  of,  87,  95. 

punctured  wounds  of,  457. 

suture  of,  91. 

Umstechung,  90. 
Arteritis,  339. 
Artery  clamps,  87. 
Arthrectomy,  139. 
Arthritis,  acute,  658. 

chronic,  668. 

deformans,  683. 

luetica,  683. 

tubercular,  672. 

urica,  663.     (See  also  Joints.) 
Arthrodesis,  133. 
Arthropathia  tabidorum,  695. 


(789) 


790 


INDEX. 


Arthrosporcs,  261. 
Artliroloiny,  129. 
Articulur  rheumatism,  658. 

acute  polyarticular,  658. 

chronic,  OG'J. 
Aseptin,  160. 
Aspergillus,  256. 
Asphyxia,  26. 
Aspiration,  70. 
Aspirators,  70,  71. 
Atheroma,  785. 

Atrophy  of  skin,  idiopalhic,  524. 
Auscultation  of  bone,  593. 
Auto-transfusion,  52,  478. 

Bacilli.  258  (see  also  the  separate  infec- 
tious diseases). 

of  diphtheria,  527. 

of  glanders,  390. 

of  malignant  oedema,  333. 

of  symptomatic  anthrax,  389. 
Bacillus  of  anthrax,  382. 

coli  communis,  334. 

of  Krnst,  325. 

of  leprosy.  438. 

of  mouse  septicaemia,  365. 

pyocyaneus,  324. 

of  rabbit  septicaemia,  365. 
Bacteria,  action  of  palhogenic,  269. 

attenuation  of  virulence  of,  270. 

conditions  suited  to  life  of,  262. 

culture  media  for,  267. 

of  decomposition,  306. 

experimental  transmission  of.  274. 

formation  of  pigment  by,  265. 

immunity  from  effects  of,  272. 

infectious,  321. 

influence    of   constant    electric   current 
upon,  263. 

influence  of  light  upon.  263. 

influence  of  oxygen  upon,  263. 

influence  of  temperature  upon,  263. 

intra-uterine  transmission  of,  275. 

linear  cultures  of,  268. 

methods  of  studying,  267. 

movements  of,  260. 

needle-point  cultivation  of.  208. 

non-pathogenic,  275. 

pathogenic,  275. 

phosphorescence  of.  265. 

power    of    oi-ganism    to    protect    itself 
against,  271. 

products  of  metabolism  of,  263,  265. 

restraint  upon  growth  of.  26(;. 

structure  and  reproduction  of,  259. 

toxic,  269. 
Bacterial  proteins,  235,  241. 
Bandasres,  application  of,  185. 

handkerchief.  194. 

for  the  head.  187. 

for  the  lower  extremity.  192. 

for  the  mamma.  189. 

for  the  neck  and  thorax,  189. 

for  the  shoulder.  192. 

for  the  upjier  extremity,  190. 


Barracks  in  war,  735. 

Docker's,  735. 
Baths,  permanent,  after  injuries,  179. 
Batteries,  electric.  77. 
Beds,  movable,  200. 
Bee  stings.  403. 
Benzoic  acid,  168. 
Bichloride  of  mercury,  155. 

effects  upon  pus  cocci,  321. 

poisoning  by,  157. 

stability  of,  156. 
Bichloride  gauze,  preparation  of,  150. 
Binoeulus,  1W». 
Birth-mark,  755. 
Bismuth,  160. 
Bistoury,  64. 
Blastomycetes,  257. 
Blood,  coagulation  of,  292. 

regeneration  of,  453. 

treatment  of  lo.ss  of,  478. 
Blood  -  corpuscles,   white,   emigration   of, 
234. 

reaction  of,  to  staining  reagents,  293. 
Blood   cysts,   757.      (See    also  Angeioma, 

Lymphangeioma,  and  Cysts.) 
Bloodless  operation,  1. 
Blood  transfusion,  479,  482. 
Blood-vessels,  530. 

aneurysms  of,  532. 

diseases  of,  530. 

injuries  of,  449. 

ligation  of,  87. 

punctured  wounds  of,  456. 

suture  of,  91. 

torsion  of,  90. 

Unistechmig,  90. 

varices,  540. 
Boiler  for  sterilisation  of  instruments,  4. 
Bones,  abnormal  fragility  of,  571. 

abscess  of,  629. 

absorbable  drains  of,  100. 

absorption  of.  583. 

acromegaly,  650. 

acromicria,  651. 

acute  inflammation  of,  609. 

acute  osteomyelitis,  610. 

atrophy  and  hypertroj>hv  of,  647. 

caries  of.  621,  628. 

chronic  inflammations  of,  618. 

crushing  of,  607. 

cysticereus  cellulosa?,  652. 

division  of,  80. 

echinococcus  of,  652. 

formation  of,  581. 

giant  growth,  649. 

gunshot  injuries  of.  730. 

implantation  of.  144. 

increased  growth  of.  582,  649. 

inflammations  and  diseases  of,  609. 

inflammaticm  of  marrow  of.  610. 

injuries  and  fracture  of,  567. 

metastatic       inflammations      of,      617, 
618. 

necrosis  of,  630. 

neuralgia  of,  692. 


INDEX. 


701 


Bones,  neuropathies  of.  693. 
in  svriiijjonivoliii,  695. 
tahelit',  (i!):}." 

operalitnis  upon,  80. 

osteomulacia,  644. 

percussion  and  auscultation  of,  593. 

plastic  surgery  upon,  HI. 

resection  of,  in  continuity,  129. 

rhachitis.  6:J8. 

sawing  of,  83. 

strength  of,  569. 

suture  of,  110. 

syphilis  of,  628. 

transplantation  of,  586. 

tuberculosis  of,  621. 

tumours  of,  652. 

uniting,  by  nails,  110. 

wounds  of,  607 
Bone  forceps,  82. 
Bone  screws,  111. 
Bone  shears,  82. 
Borated  lint,  159. 
Borax,  158. 
Boric  acid,  159. 
Boric-acid  ointment.  160 
Boro-glycerine  lanolin,  160. 
Boro-salicylic  solution,  158. 
Box  splint,  Heister's,  203. 
Branchiogenic  cysts,  786. 
Bromethyl,  42. 
Bromethylene.  43. 
Bromoform,  43. 
Bullet  forceps,  736. 
Bullets,  discovery  by  magnet  of,  736. 

extraction  of,  736. 

healing  in  of,  733. 

impaction  of,  730. 
Burns,  484. 

causes  of  death  from,  487. 

from  lightning,  491. 

prognosis  of,  489. 

symptoms  of.  486. 

treatment  of,  489. 
Bursie,  diseases  of,  558. 

Cadaver  alkaloids,  infection  by.  379. 
Cadaver  infection,  treatment  of,  381. 
Cadaver  tuberculosis,  381. 
Callosities  of  skin,  772. 
Callus,  formation  of,  581. 

delayed  formation  of,  591. 

treatment  of  delayed  formation  of,  603. 
Callus  luxurians,  585. 
Cancer  (see  Carcinoma),  774 
Cancroid,  776. 
Canquoin's  paste,  80. 
Caoutchouc  splints,  213. 
Capistrum  duplex,  188. 
Capitium  parvum,  195. 

magnum,  196. 

quadrangulare,  196. 
Caput  obstipum  (congenital),  508. 
Carbolic  acid,  152. 

demonstration  of.  in  urine,  154. 

poisoning  by,  154. 


Carbolised  gauze,  153. 

Carbolised  glycerine,  153. 

Carbolised  silk,  89. 

Cai'bonic  acid  as  an  anaesthetic,  43. 

Carbuncle,  514. 

Carcinoma,  774. 

curability  of,  783. 

etiology  of,  778. 

histology  of,  777. 

micro-organisms  of,  779. 

transmission  of,  781. 

treatment  of,  782. 
Caries  cf  bone,  621,  628. 
Caro  luxurians,  521. 
Cartilage,  fibrillation  of,  683, 

fractures  of,  575,  587. 

histology  of,  656. 

inflammation  of.  683. 

injuries  of,  575,  587. 

repair  of  fractures  of,  587. 

re{)air  of  wounds  of,  725. 
Cataplasm,  181. 
Catgut,  capillary  drain  of,  101. 

ligatures  of,  87. 

preparation  of,  88. 

sterilisation  of,  11. 

sutures  of,  105. 
Caustic  pastes,  80. 
Caustics,  different  kinds  of,  79. 

use  of,  79. 
Cauterisation  en  fleches,  80. 
Cavernonia,  757. 
Cellulitis,  331. 

prognosis  of,  337. 

svmptoms  of,  334. 

treatment  of,  337. 
Cellulose  splints,  213. 
Cement  dressing,  224. 
Chain  saw,  83. 
Cheilo-angioscopy,  305. 
Chemotaxis,  235. 
Chin  bandage,  188. 
Chionvphe  Carteri,  257 
Chisels,  81. 

Chloral-chloroform  narcosis,  42. 
Chloral  methyl  (local  aniesthetie),  46. 
Chloride  of  zinc,  159. 
Chloride-of-zinc  paste,  80. 
Chloroform,  16. 

accidents  during  narcosis  of.  25. 

apparatus  for  administering.  21. 

chemical  composition  of,  16. 

death  from,  27. 

decomposition  of,  by  gas  flame,  23. 

narcosis  of,  18. 

physiological  action  of,  17. 

poisoning  by  drinking,  30. 

statistics  of  death  from,  27 

symptomatology  of  narcosis  of.  23. 

treatment  of  accidents  during  narcosis 
of,  33. 
Chloroform-morphine  narcosis.  41. 
Chloroform-oxygen  narcosis,  32. 
Cholesteatoma,  786. 
Chondrioderma  difforma,  276. 


792 


INDEX. 


Chondroma,  751. 
Choiidroslilis  dissecans,  C38. 

luetica,  639. 
Christia,  200. 
Cicatrix,  formation  of,  249. 

malignant  neoplasms  of,  299. 

paralysis  from,  300. 

subsequent  changes  in,  299. 

tumours  of,  299,  748. 

ulcers  of,  300. 
Cladothrix,  255. 

Clamp  apparatus  for  uniting  bones,  111. 
Clavi,  772. 
Clostridium,  259. 
Club-foot,  099. 
Coagulation  necrosis,  526. 
Cocaine  (as  anaesthetic),  45. 
Cocci,  various  kinds  of,  258. 
Coccidia,  277. 
Coccus  of  gonorrhoea,  433. 
Coccus  of  sputum  septicaemia  of  dogs,  366. 
Cold,  efifects  of,  494. 

use  of,  181. 
Cold  abscess,  623,  675. 
Collateral  circulation  after  ligation  of  ar- 
teries, 296. 
Collodion,  dressings  of,  183. 
Comedones,  785. 
Compresses,  split,  116. 
Compression  (as  method  of  ha>mostasis), 

92. 
Condyloma  acuminatum.  773. 
Condyloma  latum,  430. 
f^ongestion  abscess,  623,  675. 
Conidia,  254. 

Connective  tissue,  growth  of,  284. 
(-'ontinuous  suture,  107. 
Contractures,  cicatricial,  299,  485,  705. 

inflammatory,  549. 

isch  acinic,  549. 

of  joints,  698. 

myopathic,  705. 

neuropathic.  700. 

paralytic,  702. 

spastic,  701. 
Contusions,  497. 

symptoms  of,  498. 

treatment  of,  504. 
Contusions  of  bones,  607. 
Contusions  of  joints,  707. 
Cooper's  knife,  65. 
Corpora  orvzoidea,  559. 
Corsets,  223. 

Cotton-starch  dressing,  222. 
Creolin,  169. 

Croton  oil  as  an  irritant,  236. 
Croup,  526. 
Curare,  405. 
Curative  serum.  363. 
Cushions  for  sick-bed,  202. 
Cutaneous  horns,  772. 
Cylindroma,  768. 
Cystoma,  784. 
Cysto-sarcoma,  784. 
Cysts,  784. 


Decomposition,  264. 

Decubitus,  562. 

Deformities  (contractures)  of  joints,  698. 

Delirium  nervosum,  317. 

Delirium  of  collapse,  318. 

Delirium  tremens,  316. 

treatment  of,  317. 
Dermatitis,  511. 
Dermatol,  167. 
Dermatolysis,  524. 
Dermoid  cysts,  737. 
Devouring  cells,  272. 
Dextrine  dressing,  224. 
Digital  compression  of  arteries,  47. 
Diiodthioresorcin,  167. 
Dimethylacetal-chloroform  narcosis,  42. 
Diphtheria,  bacilli  of,  527. 

etiology  of,  527. 
Diplococci,  258. 
Director,  66. 
Disarticulations,  123. 

after-treatment  of,  124. 

artificial  limbs  for,  127. 

diseases  following,  124. 

mortality  of,  127. 

performance  of,  123. 

subperiosteal,  123. 
Disinfection  of  catgut,  11. 

of  the  dressings,  11. 

of  the  field  of  operation,  8. 

of  the  instruments.  10. 

of  the  operator  and  his  assistants,  9. 

of  silk,  11. 

of  sponges,  11. 
Dislocations  of  joints,  710. 

complicated,  715. 

congenital,  721. 

of  deformity.  721. 

of  destruction,  721. 

from  distention,  721. 

habitual,  716. 

inflammatory  (pathological),  720. 

of  the  interarticular  cartilages,  720. 

intra-acetabi.  lar,  674. 

irreducible,  719. 

of  muscles,  509. 

of  nerves,  510. 

old,  719. 

of  tendons,  509. 

voluntary,  712. 
Distortion  of  joints,  708. 
Division  of  the  soft  parts,  64. 
Drainage,  98. 
Drainage  forceps,  100. 
Drains,  99. 

of  rubber  tubing,  100. 
Dressings,  antiseptic  and  aseptic,  146, 

change  of.  173. 

for  the  head,  187. 

impromptu  or  temporary,  215. 
Dressing  forceps,  67. 

Earth  tetanus,  355. 
Eburnatio  ossis,  623. 
Ecchondroses,  752. 


INDEX. 


793 


Ecchynioses,  498, 
Echiiiococcus,  053. 
of  bi)no,  (iod. 
in  the  joints,  054. 
Ecraseinent,  73. 
E.iraseur,  73. 
Hc'zeniii,  513. 
followin";  use  of  antiseptics,  513. 
solare,  4!)3. 
Kleotric  batteries,  77. 
Kleetro-p\uieture  of  tlie  heart,  30. 
Klc[)hautiasis,  5','3. 
Elevators.  81. 
Kniboli,  fat,  5!>0. 
Kiiiphyseina,  jjaiii^renotis  or  septic,  333. 

traumatic,  400. 
Eiichonilronia.  751. 
Eiularteritis,  530. 
Endothelial  cancer,  709. 
Endothelioma,  708. 
Enostoses,  753. 

Epiphyses,  spontaneous  separations  of,  037 
strength  of,  573. 
syphilitic  separations  of,  639. 
traumatic  separations  of,  589. 
Epithelial  tumours,  771. 
Epithelioma,  777. 
Epithelioma  molluscum,  773. 
Ergotine  gangrene,  503. 
Ergotism,  563. 
P]rysipelas,  339. 
cocci  of,  339. 
complications  of,  344. 
curative,  346. 
diagnosis  of,  347. 
habitual,  344. 

of  mucous  membranes,  341. 
prognosis  of,  348. 
symptoms  of,  341. 
treatment  of,  348. 
zoonotic,  351. 
Erythema,  511. 
migrans.  351. 
solare,  493. 

various  kinds  of,  511,  513. 
Erythrophkeine  as  an  anaesthetic,  46. 
Esmarch's  artificial  ischajmia,  48. 
chloroform  apparatus,  20. 
rubber  bandage,  49. 
rubber  tourniquet,  49. 
Ether,  37. 
Ethyl  acetate,  39. 

Ethyl  chloride  as  local  ana^sthestic.  45 
Eucalyptus,  168. 
Euphorin,  167. 
Europhen,  107. 
Exercise  bones,  552. 
Exostosis,  753. 
Exostosis  bursata,  090.  754. 
Extension  by  a  weight,  224. 
Extension  dressings,  technicpie  of  apply- 
ing, 334. 
modifications  of,  334. 
Extension  splints,  314. 
Extravasation  of  blood,  498. 


Extravasation  of  blood,  ab.sorption  of,  503. 

changes  in,  503. 

of  lymph,  498. 
Extremity,  upper,  dressings  for,  190. 

lower,  dressings  foi-,  lUl. 
Exudate,  various  kinds  of,  343. 

Farcy  (see  Glanders),  390. 
Fascia  lata,  shrinkage  of,  700. 
Fascia  nodosa,  187. 
P'at  eml)oli,  590. 
Favus,  350. 
Felt,  plastic,  213. 
Fermentation,  357. 
Ferment  intoxication,  300. 
Ferrum  candens,  74. 
Fever,  300. 
body  weight  in,  300. 
condition  of  respiration  in,  .305. 
condition  of  vessels  during,  305. 
definition  of,  311. 
digestion  during,  305. 
disturbances  of  nervous  system  in,  305. 
etiology  of,  307. 
explanation  of,  309. 
loss  of  heat  during,  310. 
muscular  system  in,  300. 
pathological  changes  in,  306. 
prognosis  of,  306. 
pulse  in,  304. 
symptoms  of,  303. 
treatment  of,  311. 
Fever  in  subcutaneous  injuries,  500. 
Fibroma.  747. 

molluscum,  747. 
Field  hospitals,  735. 

improvisation  of,  735. 
Filopressure,  94. 
Filter  paper  for  dressings,  153. 
Finger  bandages,  191. 
Fistula,  518. 
Flax,  150. 
Flexion,  forced,  as  a  method  of  checking 

ha?morrhage,  93. 
Foot,  dressings  for,  193. 
Foot  and  mouth  disease,  394. 
occurrence  of,  395. 
treatment  of,  395. 
Porcep.s,  toothed,  67. 
Foreign  bodies,  healing  in  of,  350. 

behaviour  in  the  wound.  461. 
Formation  of  new  tissue,  384. 
of  a  cicatrix  in  a  vessel,  390. 
of  fibrillar  connective  tissue,  285. 
of  new  vessels,  387. 
Fractures,  507. 
causes  of,  507. 
condition  of  urine  in,  580. 
diagnosis  of,  593. 

direct  fixation  of  fragments  by  nails,  su- 
tures, etc.,  597. 
disturbances  during  healing  of,  589. 
gunshot,  739. 
prognosis  of,  593. 
repair  of,  580. 


V94 


INDEX. 


Fractures,  symptomatology  of,  576. 

treatiiii'iit  of,  504. 

treatment  of  malunited,  G05. 

various  kinds  of,  572. 
Fractures  involving  joints.  5(Mi,  509.  715. 
Freezing,  404. 
Frost-bite,  404. 

blebs,  495. 
Finida  maxillie,  104. 
Fungi,  254. 

liatiiological  imjiortanoe  of,  25G. 
Furuncle,  518. 

Galvano-cautery,  75. 

instruments,  76. 
Galvano-jiuneture,  78. 
Ganglion,  5(11. 

periostale,  619. 
Gangnena  senilis,  562. 
Gangrene  foudroyante. 
Gangrene  of  the  soft  parts,  561, 

of  bone,  680. 
Genu  valgum,  701. 

varum  rhachiticum,  640. 
Germicides,  tests  and  comparisons  of,  266. 
Glanders,  390. 

in  animals,  392. 

bacilli  of,  300. 

diagnosis  of,  394. 

in  man,  392. 

treatment  of,  394. 
Glass  splints,  211. 
Glass  wool,  152. 
Glioma,  763. 

Glisson's  sling  for  extension,  230. 
Glue  dressing,  224. 
Glycerine-salt  dressing  material,  152. 
Gonocopcus,  433. 
Gonorrhcwa,  433. 
Gonorrhoeal  rheumatism,  662. 
Gout,  663. 

Gout  of  lead  poisoning,  664. 
Granulations,  formation  of,  280. 

anomalies  of,  521. 
Gregarines,  277. 
Gum  and  chalk  dressing,  224. 
Gummata,  430. 
Gum  mi  lacca-,  183. 
(Jutta-percha  splints,  213. 
Gymnastics.  215. 
Gv[)sum  dressing,  216. 

"knife  for,  221. 

scissors  for,  221. 

various  methods  of  apijjying,  217. 
Gypsum  splints,  220. 

Il.'Pmarthros.  707. 
IlaMiiatoma,  40S. 

absorption  of,  502. 

changes  in,  503. 
Hannophilia,  57. 

Joint  diseases  complicating,  686. 
Haemorrhage,  arrest  of,  86. 

arterial,  449. 

capillary,  450. 


Haemorrhage,  causes  of  death  from,  452. 

death  from,  452, 

effects  of,  451. 

prevention  of,  during  operations,  47. 

regeneration  of  blood  after,  453. 

secondary,  477. 

treatment  of,  478. 

venous,  450. 
Ilaemostasis,  86.' 

temporary,  465. 
Hairy  j)eople,  756. 
Hammer,  surgical,  81. 
Hand,  bandages  for,  191. 
Hand  spray,  12. 
Healing  beneath  a  scab,  177. 

microscopic  phenomena  in  the  healing 
of  a  wound,  282. 

per  primani  intentionem,  280. 

per  secnndam  intentionem,  281, 
Heister's  cradle  or  box  splint,  203. 
Flip,  bandages  for,  193, 
Histocym,  308. 
Hollow  needles,  69. 
Hollow  probes,  66. 
Hospital  gangrene,  351. 

clinical  course  of,  353. 

etiology  of,  353. 

prognosis  of,  353, 

treatment  of,  353, 
Howship's  lacunje,  583, 
Hydarthros,  acute,  658. 

chronic.  667. 
Hydrophobia,  395. 

action  of  poison  of,  397. 

attenuation  of  the  poison  of,  397. 

diagnosis  of,  400. 

in  dogs,  398. 

etiology  of,  395. 

experiments  upon,  396, 

in  nuxn,  398. 

prognosis  of,  401. 

protective  inoculation  with,  401. 

results  of  autopsy  in,  400. 

treatment  of,  401. 
Hygroma  of  bnrsje,  559. 

of  tendon  sheaths,  558. 
Hyperostoses,  620. 
Hypertrichoses  circumpcri[)ta,  756. 

univei'salis,  756. 
Hyj)odermic  needle,  71. 
Hysteria  after  injuries,  279,  546. 
Hysterical  joint  diseases,  690, 
Hystricisnius,  773. 

Ice,  use  of,  181, 
Ice  bags,  ISl. 
Ichthyol,  170. 
Icthyosis,  773. 
Immersion,  179. 

Immnnity,  natural  and  artificial,  321, 
Improm{)tu  dressings,  194. 
Indian  arrow  poison,  405. 
Infantile  spinal  paralysis,  703. 
Infection  from  cadaver  alkaloids,  379. 
intra-uterine,  416,  427. 


INDEX. 


Inrootious  wound  disoasos,  .'{18. 

urii^iii  of,  Ity  iniiTobcs,  .'51H. 

viirioiis  kinds  of,  ;5LH)— 105. 
iMtliUiiMialioii.  242. 

causes  of,  2'M!. 

croupous  aud  diiilitluTitic.  244. 

dia^uositf  and  treat lueiit  of,  251. 

of  joints,  G58. 
acute,  058. 
chronic,  6(57. 

movements  of  lympli  in,  235. 

nature  of.  238. 

symptomatology  of,  241. 
Inliammation  and  suppuration  of  wounds, 

320. 
Infusion  of  salt  solution,  478. 

indications  for,  481. 

technique  of,  481. 
Initial  sclerosis  of  syphilis,  428. 
Injections,  parenchymatous,  71. 
Injuries,  general  remarks  upon,  277. 
Insects,  injuries  inflicted  by,  403. 
Insolation,  492. 

Instruments,  sterilisation  of,  10. 
Iodine,  168. 

as  an  antiseptic.  168. 

demonstration  in  urine  of,  166. 
Iodine^  trichloride  of,  109. 
Iodoform,  100. 

behaviour  of,  towards  bacteria,  162. 

with  formic  acid,  161. 

poisoning  by.  163. 
Iodoform  collodion,  183. 
Iodoform  gauze,  161. 
Iodoform  wick,  162. 
lodol,  167. 
Iron,  red-hot,  74. 

Irrigation,  permanent,  of  wounds,  178. 
Irrigator,  179. 
Ischiemia,  artificial,  48. 
Ischnemic  contractures,  549. 
Ivory  pegs,  insertion  in  bone  of.  111. 

Joints,  anatomy  of,  655. 
anchylosis  of,  096. 
cartilage  of,  657. 
contractures,  of,  698. 
deformities  of,  698. 
■  diseases  of,  in  bleeders  (haBinophilia),  686. 
echinococcus  of,  654. 
endothelium  of,  655. 
histology  of  articular  cartilages  of,  657. 
inflammations  of,  058. 
acute.  658. 
chronic,  067. 

arthritis  deformans,  683. 
gout,  663. 
syphilis,  682. 
tuberculosis,  673. 
gonorrhoea! ,  062. 
metastatic,  661. 
rheumatic,  609. 
injuries  of,  707. 
contusions,  707. 
dislocations,  710. 


Joints,  gunshot  injuries  of,  727. 
punctured  wounds,  724. 
sprains  or  distortions,  708. 
wounds,  724. 
lymph  vessels  of.  657. 
neuropathic  in  (lain  mat  ions  of,  093. 
neuroses  of,  ()9(). 
resection  of,  129, 
synovia  of,  658. 
synovial  villi  of,  650. 
Junker's  chloroform  apparatus,  21. 
Jury  mast,  229. 
Jute,  149. 

Kappeler's  chloroform  apparatus,  21. 

Keloid.  299,  748. 

Keratoma,  772. 

Knee,  bandages  for,  193. 

Knife,  forms  of,  04. 

methods  of  holding,  05. 
Kyphosis,  075. 

Lacerated  wounds,  463. 
Lancets,  64. 
Lanoline,  183. 

Laryngeal   mucous  membrane,  ana?sthesia 
of,  by  irritation  of,  with  chloroform 
or  carbonic  acid,  43. 
Laughing  gas,  narcosis  of,  89. 

combined  with  oxygen,  40. 
Lead  plates  for  suturing,  108. 
Leather  splints  and  bandages,  213. 
Leg,  bandages  for,  192. 
Leontiasis,  747. 
Leprosy,  437. 

bacilli  of,  438. 

diagnosis  and  prognosis  of,  441. 

occurrence  of,  439. 

symptoms  of,  439. 

treatment  of.  441. 
Leptothrix,  259. 

Leucocytes,    different     reactions   towards 
staining  materials,  293. 

emigration  of,  235. 
Leucocytosis,  inflammatory,  241. 
Lifts  for  sick-bed,  201. 
Ligature  en  masse,  72. 

of  vessels,  87. 
Lightning,  action  of,  491. 
Lint,  149. 
Lipoma.  750. 
Lipoma  arborescens,  689. 
Lister's  method  of  treating  wounds,  147. 
Liver,  collection  of  blood  in  the,  502. 
Lues,  425. 
Lupus,  515. 

Lymph,  movements  of,  during  inflamma- 
tion, 235. 
Lymphadenia  ossium,  651. 
Lymphadenitis,  326. 
Lymphangiectasis,  543, 
Lymphangieoma,  758. 
Lymphangitis,  326. 
Lymphatics,  acute  inflammation  of,  326. 

diseases  of,  543. 


196 


INDEX. 


Lymph  fistula,  544. 

Lvmph    glands,   acute    inflammation   of, 
32G. 

collection  of  blood  in,  502. 

diseases  of,  326. 
Lymphoma,  763. 
Lym()horrhagia,  544. 
Lvmphorrhoea,  544. 
l/vsol,  169. 
Lyssa,  395. 

Madura  foot,  257. 
Magnesite  dressing,  224. 
Magnetic  needle  for  extraction  of  metallic 
foreign  bodies,  66,  4Ty. 

for  extraction  of  bullets,  736. 
Malaria,  protozoa  in,  277. 
Malformations,  649. 
lyialleus,  390. 

.Malum  perforans  pedis,  564. 
Malum  senile,  683. 
Mamma,  dressings  for  the,  189. 
Marly  scraps  for  dressings,  151. 
Marrow  of  bone,  actinomycosis  of,  630. 

chronic  inflammations  of,  618. 

echinococcus  of,  652. 

metastatic  inflammations  of,  617. 

scraping  out  of,  615. 

syphilis  of,  628. 

traumatic  inflammations  of.  617. 

tuberculosis  of.  621. 
brassage,  technique  of,  505. 
^^lelanoma,  769. 
Menthol  as  anaesthetic,  45, 
Mercurial  cachexia,  436. 
Metal  s[)lints,  209. 
Methvlol.  36. 
>rethyl  chloride.  .36. 
Methylene  bichloride,  36. 
Methylene  compounds,  36. 
Methylene  ether,  30. 
Methyl  ether,  36. 

Microbes,  importance  of,  in  inflammation, 
257. 

importance  of,  in  fever.  309. 

methods  of  examining,  267. 

morphology  of,  259. 

of  suppuration,  321. 
Micrococci.  258. 
Micrococcus  pyogenes  tenuis,  325. 

tetragonus,  258. 
Miliaria,  513. 
Milium,  785. 
Milk  infusion,  484. 
Mitella.  197. 
i\Iitra  Hippocratis,  188. 
Mollin,  184. 

Molluscum  contagiosum,  773. 
Monilia,  255. 
Monoculus,  189. 
Morphine-chloroform  narcosis,  41. 

-ether  narcosis,  42. 
Moss,  150. 
Moss-felt  pads,  150. 
Moss  pulp,  151. 


Mouse  septicaemia,  bacilli  of,  .365. 
Mouth-and-hoof  disease,  394. 
Mouth-gag,  22. 
Mouth  speculum,  22. 
Mucin  poisoning,  359,  523. 
Mucor  corymbifer,  256. 
.rhizopofioformis,  256. 
Mucous  membrane,  inflammations  of,  525. 

transplantation  of,  143. 
Mull,  149. 

sterilised  pledgets  of,  11, 
Mures  articulares,  687. 
Muscles,  diseases  of,  549,  553. 

hernia  of,  509. 

injuries  of,  506. 

luxations  of,  509. 

regeneration  of,  408. 

suture  of,  468. 

transplantation  of.  468. 
Muscular  rheumatism,  .553. 
^lycetozoa,  276. 
Myoma,  759. 
Myositis  serosa,  550. 

fibrosa,  551. 

ossificans.  551. 
Myxoedema.  523. 
Myxoma,  749. 
Myxomyeetes,  276. 

Xaevus  vasculosus,  755. 

Naphthaline,  167. 

Narcosis  with  chloroform-air  mixture,  29. 

chloroform-morphine,  41. 

ehlorofonn-oxvgen,  32. 

ether,  37. 

by  irritation  of  laryngeal  mucous  mem- 
brane, 43. 

laughing  gas,  39. 

mixed,  40. 
Nearthrosis,  formation  of,  686,  713. 
Neck,  dressings  for,  189. 
Necrosis  of  bone,  630. 

of  soft  parts  (gangrene),  561. 
streptococci  in,  332. 
Necrotomy,  636. 
NeefUe-holder,  104. 
Needles,  104. 
Nephritis  carbolica.  164. 
Nerves,  defects  of,  471. 

degeneration  of,  after  injuries  of,  454. 

diseases  of,  545. 

grafting,  470. 

injuries  of,  453,  459. 

luxations  of,  510. 

neurectomy,  548. 

regeneration  of.  454.  473,  474. 

stretching  of,  470,  547. 

suture  of,  469. 

transplantation  of,  471. 

treatment  of  defects  of,  470. 
Nervus  phrenicus,   electrical    stimulation 

of,  in  asphyxia,  35. 
Neuralgia,  547. 

of  bones,  692. 

of  joints,  690-692. 


INDEX. 


797 


Xeureetomy,  548. 
Neuritis.  545. 
Neurofibroma,  747. 
Neuroplioma  gaiigiionare.  7C3. 
Neuroma,  700. 

malignant,  7r)2. 

plexiform,  7(>1. 
Neuropathic  inflammations  of  bones  and 

joints.  693.^ 
Neurorrhaphy.  4(39. 

after-treatment  of.  472. 

histological  changes  after,  475. 

results  of,  473. 

secondary,  470. 
Neuroses,  traumatic.  279.  546. 

following  operations,  63. 
New  formation  of  tissue,  284^ 
New  formation  of  vessels,  287. 
Noma,  525. 

Occlusion,  antiseptic,  in  army  surjery,  733. 
Occlusive  dressings,  antiseptic.  UG. 
Odontoma,  754. 
G^^dema,  malignant.  333. 

bacilli  of.  333. 
Oidium,  255. 
Oil-cysts,  788. 
Onychoma,  772. 
Operating  tables,  6,  7. 
Operation.  1. 

accidents  in  the  course  of.  56. 

after-treatment  of,  61. 

alleviation  of  pain  in,  14. 

aseptic,  2. 

causes  of  death  in,  62. 

definition  of,  1. 

healing  of  wounds  made  in  the  course 
of.  61,  280. 

indications  and  contra-indications,  2. 

neuroses  following.  63. 

preparations  for,  2. 

preparations  for.  in  private  practice,  13. 

saving  of  blood  during.  47. 
Operator,  clothing  of.  9. 

disinfection  of  clothing  of,  9. 
Organisation  of  a  thrombus,  290. 
Osteoblasts.  582. 
Osteochondritis.  629,  638. 

dissecans,  638. 

luetica.  629. 
Osteoclasis.  84. 
Osteoclastic  cells.  583. 
Osteoclasts.  84,  583. 
Osteoma.  753. 
Osteomalacia,  644. 

anatomical  changes  in.  645. 
Osteomyelitis,  acute  primary,  610. 

anatomical  changes  in,  612. 

clinical  course  of.  613. 

diagnosis  and  prognosis  of,  614. 

etiology  of.  610. 

treatment  of,  614. 
Osteomvelitis.  chronic,  618. 

syphilitic,  628. 

tubercular,  621. 


Osteomyelitis,      tubercular,      anatomical 
changes  in,  621. 

clinical  course  of,  024. 

diagnosis  and  prognosis  of,  625. 

treatment  of,  620. 
Osteophonia,  593. 
Osteophyte,  619. 
Osteoplasty,  586. 
Osteoporosis,  647. 
Osteopsatyrosis,  571. 
Osteosarcoma,  755. 
Osteosclerosis,  648. 
Osteotome,  84. 
Ostitis,  514. 

Paper-starch  dressing,  222. 

Papier-mache  splints,  209. 

Papilloma,  771. 

Paquelin"s  thermo-cautery,  74. 

Paraffine  splints,  213. 

Paralysis  of  heart  from  chloroform,  26. 

electro-puncture  for,  36. 
Paralysis,  infantile  spinal,  703. 
Parenchymatous  injections,  71. 
Paronychia,  335. 
Pasta  cerata,  184. 
Peat,  150. 

Pelvis,  bandages  for,  193. 
Pemphigus,  513. 
Penghwaer  djambi,  93. 
Penicillium  glaucum,  255. 
Pental  narcosis.  43. 
Percussion  of  bone.  593. 
Percutaneous  ligation  (of  vessels).  90. 
Periarteritis,  329. 

Periosteum,  inflammations  of.  609. 
Periostitis,  albuminoid  or  mucinoid,  019. 

chronic  ossifving,  620. 

syphilitic,  628. 

tubercular,  621. 
Periphlebitis.  329. 
Peroxide  of  hydrogen,  169. 
Pes  calcaneus  paralyticus,  702. 

equino  paralvticus,  702. 

valgus.  700.  701. 

varus.  699.  700. 
Petit's  leg  splint,  203. 
Phagocvtes.  272. 
Phenol,'  152. 
Phlebectasiap,  540. 
Phlebitis,  329. 
Phlebotomy,  458. 
Phlegmasia  alba  dolens.  339. 
Phlogosin.  241. 
Phosphorus  necrosis.  631. 
Photoxylin,  183. 
Pityriasis  versicolor,  255. 
Plasmodia.  276. 
Plasmodiophora  Brassicae,  276. 
Plasmodium  malariae.  277. 
Plaster  of  Paris,  splints  of,  216. 
Plastic  operations,  134. 
Plexiform  neuroma,  761. 
Pneumococcus.  325. 
Poison,  cadaveric,  379. 


'98 


INDEX. 


Poisoning  by  insects  and  snakes,  403. 

Poultice,  antiseptic,  181. 

Pressure  paralysis  from  cicatrix,  300. 

Projectiles  from  firearms,  effects  of,  727. 

Protozoa,  277. 

I'seudarthrosis,  591. 

i'seudo-tuberculosis,  412. 

Ptomaines,  264. 

Pulse  in  fever,  304. 

Punctured  wounds,  456. 

of  cavities,  459. 

of  joints,  459,  724. 

of  nerves,  459. 

of  vessels,  457. 
Pus,  247. 

blue,  247. 

green,  247. 

red,  247. 
Pus-corpuscles,  origin  of,  246. 
Pus  microbes,  321. 
Putrefaction,  bacteria  of,  366. 
PyaMuia,  373. 

clinical  course  of,  376. 

diagnosis  of,  378. 

etiology  of,  373. 

occurrence  of,  376. 

pathology  of,  374. 

prognosis  of,  378. 

treatment  of,  378. 

Rabies,  395. 

Kag-sortei''s  disease,  836. 
Railway  injuries,  279. 
Ileaction   following   injurv   or   inflamma- 
tion. 300. 
Red-hot  iron,  74. 

for  haeraostasis.  93. 
Red  pus,  325. 
Regeneration  of  tissues.  250-298. 

of  nerves,  454. 

of  tendons,  469. 
Reproduction  of  bacteria,  259. 
Respiration,  artificial,  34. 
Retentive  dressings,  216. 
Retractors,  68. 

Reunion  of  entirely  severed  parts,  290. 
Rliachitis.  638. 

anatomical  changes  in,  639. 

the  course  of,  642. 

the  diagnosis  of,  642. 

the  etiology  of,  641. 

the  treatment  of,  643. 

Saccharomyces.  257. 
ftalicvlic  acid,  158. 
Salveol,  170. 
Salves.  183. 

Scab,  healing  under  a,  177. 
Scissors,  68. 
Scleroderma,  524. 
Scrofula,  treatment  of,  424. 
Scurvy  or  scorbutus,  521. 
Secondary  haemorrhage,  47 
Septicemia.  363. 
of  animals.  365. 


Septicfpmia,  clinical  course  of,  868. 

cryptogenetic,  363. 

diagnosis  of,  371. 

etiology  of,  363. 

occurrence  of,  367. 

pathological  changes  in,  367. 

prognosis  of.  371. 

treatment  of,  372. 
Sequestrum,  separation  of,  632. 
Sequestrotomy,  636. 
Shock,  313. 

etiology  of,  313. 

symptoms  of,  314. 

treatment  of,  315. 
Shot-suture,  109. 
Sick-bed  of  the  patient.  200. 
Silk,  preparation  of,  89. 
Size,  daily  variations  in,  651. 
Skin,  burns  of,  484. 

callosities  of.  772. 

contusions  of,  461. 

diseases  of,  510. 

frost-bites  of,  494. 

horns  of,  772. 

injuries  of,  448. 

opening  for  drainage,  101. 

plastic  operations  upon,  134. 

polypus  growths  of.  788. 

transplantation  of,  141. 
Skin-grafting,  141. 
Skin-muscle  canalisation,  101.  ' 

Skinning  over  of  granulation  wounds,  281. 
Snake-bites.  403. 

Sodium   chloride,   addition   to   bichloride 
solution  of,  156. 

impregnation  of  dressings  with,  152. 

for  treatment  of  wounds,  170. 
Sodium  chloride  infusion,  482. 
Sodium  tetraboricum.  160. 
Soft  chancre,  432. 
Spastic  stiffness  of  joints,  701. 
Spirillum,  259. 

Splints  of  plaster  of  Paris,  216. 
Spoon,  sharp,  72. 
Sprains  of  joints,  708. 
Spray.  12. 

Starch  dressing,  222. 
Steam  spray,  12. 
Steam  sterilising  apparatus,  4. 
Stenocarpine,  46. 
Sterilisation  of  catgut,  11. 

of  dressings.  11. 

of  instruments,  10.  • 

of  silk.  11. 
Sticking  plaster,  extension  by,  225. 

various  kinds  of,  182. 
Sticking-plaster,  mull,  182. 
Streptococcus  pyogenes,  323. 
Structure  and  reproduction  of  bacteria,  259. 
Subcutaneous  rupture  of  muscles  and  ten- 
dons, 506. 

treatment  of,  508. 
Subcutaneous  salt  infusion,  484. 
Sulphocarbolate  of  zinc,  168. 
Sun-burn.  492. 


INDEX. 


Y99 


Sun-stroke,  403. 

treatment  of,  4!):5. 
Suppuriition,  causes  of,  340. 
■    importance  of  microbes  in,  357. 

various  kinds  of,  34;J. 

various  kinds  of  microbes  of,  331. 
Suspension  apjxiratus.  304. 
Suture,  continuous,  107. 

interrupted,  100. 

of  nerves,  4ti!(. 

secondary,  10!). 

of  tendons,  4t)0. 

of  vessels,  01. 
Suture  materials,  105. 
Svucope,  37. 
Sypliilis,  435. 

changes  in  blood  in,  431. 

course  of,  4:}3. 

immunity  from,  433. 

inheritance  of,  437. 

origin  of,  437. 

symptoms  of,  438. 

transmission  of,  to  animals,  436. 

treatment  of,  433. 
Syphilis  maligna,  437. 
Syphilitic  albuminuria,  433. 

dental  deformities,  433. 

pseudo-paralysis,  433, 

Temperature  of  body  in  fever,  301. 

Temporary  dressings, l04. 

Tenoplasty,  467. 

'i'enorrhaphy,  466. 

Tenosynovitis.  566. 

Tenotome,  67. 

Tenotomy,  558. 

Teratoma,  787. 

Terebene,  168. 

Tetanus,  bacillus  of,  356. 

clinical  course  of,  359. 

etiology  of,  354. 

of  the  head,  360. 

hydrophobicus,  400. 

immunity  from,  358. 

pathogenesis  of.  356. 

poison  of,  357. 

prognosis  of,  361. 

traumatic,  354. 

treatment  of,  361. 
Tetany,  359. 

Tetraboride  of  sodium,  160. 
Therrao-cautery,  Paqnelin's,  74. 
Thrombus,  organisation  of,  290-394. 

red,  white,  and  mixed,  391. 

subsequent  changes  in,  294. 
Thymol,  159. 
Tissue,  division  of,  64. 

formation  of,  384. 

regeneration  of,  250,  398. 
Toothed  forceps,  67. 
Tourniquets,  48. 
Toxines,  364. 
Transfusion  of  blood,  479-483. 

dangers  of,  480. 

indications  for,  481. 


Transfusion  of  l)lood,  technique  of,  481. 

Traumatism,  183. 

Trichloride  of  iodine,  16.9. 

Tripolith  dressing,  223. 

'I'rismus,  354. 

1'rocar,  (iO. 

Tubercle,  anatomical,  380. 

Tubercles,  origin  and  structure  of,  407. 

Tuljercle  l)aciili,  408. 

of  birds,  413. 

demonstration  of,  414. 

staining  of,  410. 

toxine  of,  409. 
Tuberculosis,  400. 

of  bones  and  jtjints,  419. 

of  cattle,  411. 

combined  with  syphilis  and  cancer,  413<, 

diagnosis  of,  430. 

extension  of,  413. 

inheritance  of,  415. 

of  lips,  rectum,  etc.,  418. 

of  lymph  glands,  420. 

of  mucous  membranes,  417. 

of  nose,  418. 

origin  of,  in  man,  412. 

of  pharynx,  palate,  etc.,  418. 

prognosis  of,  420. 

of  subcutaneous  tissue,  416. 

termination  of,  415. 

of  tongue,  417. 

transmission  of,  to  animals,  411. 

transmission  of,  to  frotus,  416. 

treatment  of,  420. 

treatment  of,  with  tuberculin,  421. 
Tumours,  738. 

in  animals,  741. 

clinical  course  of.  742. 

curability  of  malignant,  744. 

diagnosis  of,  744. 

etiology  of,  739. 

growth  of,  742. 

transmissibility  of,  741. 

treatment  of,  745. 

various  kinds  of,  with  their  treatment, 
744. 

Ulcers,  cicatricial,  300. 

irritable,  522. 
^  of  skin,  518. 
Crine,  condition  of,  in  fractures,  580. 

condition  of,  in  rhachitis,  641. 

Vaccination  lancet,  64. 

Varices,  540. 

Venesection,  458. 

Verruca  necrogenica,  380. 

Vessels,  behaviour  of,  in  fever,  305. 

formation  of,  cicatrix  in,  294. 

formation  of  new,  287. 

ligation  of,  87. 

ligation  of.  en  masse,  90. 

other  methods  of  haemostasis,  92. 

suture  of,  91. 
Vibrio.  259. 
Villi,  synovial,  656. 


800 


INDEX. 


Wandering  of  the  aeetabulmn,  074,  675. 

Wilier-glass  dressing,  223. 

Whitlow,  ;«5. 

Wire  splints  and  gutters,  210. 

Wire  stocking,  Bonnet's,  211. 

Wood-fibre  dressing,  151. 

Wood-fibre  pads,  151. 

Wooden  splints,  205. 

Wood  wool,  151. 

Wounds,  foreign  bodies  in,  461. 

gaping  of,  449. 

hjemorrhage  from,  449. 

healing  of,  280. 


Wounds,  infectious  diseases  of,  318. 

inflammation  and  suppuration  of,  320. 

of  muscles  and  tendons,  453. 

of  nerves,  453. 

repair     of,     in     non-vascular     tissues, 
297. 

of  soft  parts,  448. 

suture  of,  104. 

symptomatology  of,  448. 

treatment  of.  464. 
Wound  pain,  448. 

Xanthoma,  769. 


TEE  END. 


^yn-r-^^'o  -t^^'^---  o^^^-^-^^' 


/ 


RO  31  T46  1897  C.l 

Tiiepnnnv,i;;;i,;;,\,;ilrt,\\liii'ii(iirt^^^ 


2002189348 


J 


RD31 

Tillmanns 

Text-book  of  surgery 


J''        4   \.,U 


